NORTH BROOKFIELD, Mass. -- It's been some time since the North Brookfield Emergency Medical Service has been on sound financial footing, and its future is uncertain at best.
And among private, nonprofit ambulance services in Central Massachusetts, that is more and more the norm, rather than the exception.
In a league of their own, the nonprofits don't have the revenue stream of private "for-profit" ambulance services that do more patient transports than emergency runs, nor do they have the access of municipal ambulance services to taxpayer dollars.
Rather, they survive on subscriptions, donations, grants and careful management of resources to continue to answer 911 calls.
Patrick Kiritsy, director of North Brookfield EMS, cited a litany of changes at the local, state, and federal level that could guarantee service from one year to the next, but for now almost $100,000 in billed ambulance service is outstanding, and that worries Selectman Jason Petraitis, among others.
Mr. Kiritsy can understand the selectman's concern.
"Come the day that we can't meet payroll, we close the door, turn off the lights and then it's up to the town to contract for emergency service elsewhere," he said.
Mike Emerson, billing coordinator for the Barre Rescue Squad and other ambulance services using the parent company Action Ambulance of Wilmington, said, "This is a huge, huge issue across the board affecting not just small towns like North Brookfield, but all public and private ambulance services, profit and nonprofit."
Among the issues affecting emergency medical services, a major one is patients without health insurance, said Mr. Emerson. Another factor, he said, is the steady decline in Medicare and Medicaid reimbursement rates, which are based on "fair market value."
He said Medicare pays something in the vicinity of $400 for a 911 ambulance call. Only a base rate and mileage can be charged. Medicare doesn't pay for supplies. Some cost $70 or $80 for a one-time use, and the service is left picking up the tab to replenish them, he said.
Mr. Emerson said he spends about 20 hours a month reviewing accounts, forwarding them to a collection agency.
"On average, 10 to 15 percent of everything I bill each month is going to a collection agency. Take Barre, for instance, I think I sent two months' worth of overdue accounts to collection and that represents about $30,000. For a smaller ambulance service that's a significant amount of cash - and there's no guarantee it will ever be collected," he said.
He said the greatest challenge he faces are patients who receive "free care," which covers hospitalization, but not ambulance service.
"If you're a patient receiving free care at a hospital, what are the chances of us ever recovering the cost of that ambulance ride?" he asked.
Mr. Emerson said the economy is driving up the volume of ambulance calls across Massachusetts.
"People can't afford to go to the doctor so they wait until they are so sick they have to go to the hospital, and end up calling for an ambulance to get them there," he said.
"This is not a providers' market. There is no picking or choosing whom you transport. When a 911 call comes in, some EMS crew is obligated to provide the service," he said.
Given the trends he's seen over the past decade, Mr. Emerson predicted that many of the marginal private nonprofit ambulance services will either be incorporated into town government or cease to exist.
Paul Lupacchino, president of the West Brookfield Rescue Squad, said allowing insurance companies to pay patients for ambulance services and make the patient responsible for paying the ambulance service is counterproductive at best.
"Given the state of the economy, we have reason to be concerned. That check might just as easily go toward paying the heating bill, rent or groceries," he said.
"What is even more troubling is the potential for abuse where an individual calls 911 for ambulance for a non-emergency transport to a local health facility with the expectation of receiving a check in the mail in a couple of months to support an addiction or buy a nice dinner at a restaurant - at the expense of the rescue squad," he added.
"Without the continued support of the community through subscriptions and donations, I don't know where we'd be," he said.
He said a $35 family ambulance subscription more than pays for itself, with the rescue squad offsetting the patient's copay or deductible by $250 for each call.
Brendan McCarthy, manager of the Brimfield Ambulance Service, said he's had to make significant administrative cuts to keep that nonprofit service afloat.
Mr. McCarthy said Brimfield uses Comstar for its billing and expects a return of about 45 to 50 cents for each dollar billed. The Brimfield service covers calls from Holland and Wales as well.
"I'd like to see both state and federal legislators take a look at what we do, the services we offer, the costs we incur. They'd see that reimbursement rates don't come close. Most of the 911 patients are transported to Wing Memorial in Palmer or Harrington in Southbridge."
Gary Milliard Jr., chief of Webster Emergency Medical Services, said that aside from unrealistic reimbursement rates, major insurers are pushing ambulance services into signing a contract at reduced rates in order to receive direct payment for patient services. Otherwise, he said, the patient is sent the check.
One of the larger private nonprofits in the region, Webster Emergency Medical Services has volume of more than 6,700 calls a year, said Mr. Milliard,
"The ambulance business of the 1980s was a good revenue generator. I could send out a bill for $5,000 and expect to get paid ... every nickel, but that just doesn't happen anymore. Everyone is trying to cut back on the rising costs of health care, except in this case the cuts are jeopardizing our ability to provide the service."
Mr. Milliard said Webster does not have subscribers but accepts donations and is successful to the degree that the service lives within available resources.
Bert DuVernay, New Braintree police chief and former coordinator for the Hardwick Rescue & Emergency Squad, said that at one time the merger of the Hardwick and North Brookfield squads had been proposed because Hardwick's 200 calls a year and New Braintree's 50 calls a year were not enough to keep skills sharp. At the time, he said, Hardwick was truly a "volunteer" service.
"It wasn't a question of money then, which it is now, because Hardwick's EMTs weren't paid for their time or services," Mr. DuVernay said.
"When Medicare, Medicaid and MassHealth pay about a third of what's billed, and the major insurance companies pay what they please when they get around to it, then something has to be done or services like ours won't survive. I still think regionalization is one part of the equation," the chief said.
Mr. Kiritsy was the one who advised selectmen in 2010 that the cost of maintaining an around-the-clock advanced life support service at $540,000 had become an albatross. Rather than ending the service, it was decided to downgrade it to a basic life support squad.
Now even that is a challenge, he said, citing what he called "absurdly low reimbursements" from Medicare, Medicaid and MassHealth for ambulance transport.
"As of today, we're fully staffed; operational 24-7; and we run an on-call service. Our EMTs are paid for the eight-hour shift that they are on call as well as a stipend if they get called out," Mr. Kiritsy said.