FORT MORGAN, Colo. - When the buzzer sounds in the Morgan County ambulance station, it's another chance to save a life in the rural farm and ranch community.
It's also another chance to lose some serious money.
The slip-and-fall call from a 72-year-old woman on this blustery November day will produce a vital rescue from a lifeline service in an aging county.
It will also likely be a steep write-off for the county's enterprise fund, which gets back only 7 cents on a dollar billed for its numerous Medicaid runs. For the many other uninsured patients, the bills often return zero.
Morgan County Ambulance Service has been dipping into a reserve fund every year to cover losses but now faces a budget crisis hitting many rural ambulance services in Colorado.
The Ambulance Service gets no tax revenue from the county, relying solely on its billing to patients. Other counties from Summit to Bent to Logan have searched for more permanent funding solutions to preserve their communities' links to emergency health care.
"We're acutely aware that rural areas will be struggling more and more," said Randy Kuykendall, chief of trauma services for the Colorado Department of Public Health and Environment.
Kuykendall is consulting with multiple counties about how to preserve ambulance companies and trying to free up state grants for equipment and other one-time costs. "At the end of the day, it comes down to local decisions about what level of service they want to maintain," he said.
Morgan County ambulance director Bob Walter and paramedic Joe King choose their safer and cheaper converted Chevy Suburban ambulance for the slip-and-fall call and many other runs. Walter pioneered full-service SUV ambulances for this part of Colorado in one of his many penny-pinching efforts to preserve the endangered ambulance company.
They get blown around less than the regular boxy ambulances, can perform all lifesaving functions for one patient and save significant money on the Morgan County service's average of six trips a day.
"We're out of ideas, and we're out of cuts," Walter said. "In a year, we're out of funding." Some of the ambulance revenue losses across Colorado come as the result of good news.
When state highway officials straightened out two dangerous curves on Interstate 76, traffic accidents dropped from the No. 1 source of Morgan County ambulance calls to No. 4. While trauma workers are happy to forgo accident patients, the reality is an interstate driver is more likely to have insurance to pay an ambulance fee than a poor county resident.
When a hospital opened in Summit County in 2005, Summit County Ambulance Service immediately lost lucrative runs from ski resorts to orthopedic centers in Vail and Denver.
With no backup from government coffers, places like Summit have to get creative to find money.
"I have patients that are paying $20 a month for five years," said Summit County ambulance director Marc Burdick. "And we will absolutely accept that if they get on a payment plan with us."
County efforts to balance declining ambulance budgets range from "subscriptions" to combing classified auto ads.
Morgan County's service sold $17,500 in memberships last year. Ambulances will pick up everyone, of course, but if the patient is a paid subscriber, large discounts apply.
Walter closed one ambulance site in Wiggins and merged it with the Wiggins fire department to save costs. He wants Morgan County to consider a dedicated ambulance tax or to seek contributions through local utility bill checkoffs as a Texas district has done. The county currently loses $10,000 to $12,000 a month.
Logan County has one of the few private rural services left, but the owner is willing to get bought out to stop his losses. Doug Smith's contract with Logan County hasn't gone up for six years, while the aging farm population requires more and more runs.
"People over 60 need about 20 ambulance runs a month per 1,000 population," Smith said. "Under 30 years old, it's about one run a month."
As in Morgan County, frequent runs to higher-level medical centers in Denver or Fort Collins can tie up an ambulance for four hours.
State officials are consulting with Logan County on possible solutions, including a tax authority and buyout of Smith's Life Care ambulance.
"We're on a collision course with disaster if we don't do something," Smith said.
Summit County will consider a dedicated property tax and other potential revenue sources to support the $3.9 million annual ambulance cost. Burdick said the county averages higher reimbursement from patients because of vacationers with private insurance but still takes in only 68 cents of every dollar billed.
Summit County has cut the number of ambulances on the road during winter months to save money. It also partners with Flight for Life to provide a critical-care ambulance unit when weather makes mountain flights impossible.
Transcare, a private ambulance provider in western and southeastern Colorado, specializes in hospital-to-hospital transport. Two hospitals subsidize Transcare's poor-paying Medicare and Medicaid runs, said chief executive Allen Hughes.
Hughes sympathizes with public ambulances that take all 911 calls, and may or may not get reimbursed for a run. His ambulances serve as backup-only for public 911 services. Transcare keeps costs down with used equipment.
"I wait until a fire department has a 5-year-old ambulance with 50,000 miles on it, for $20,000, instead of buying a new one for $120,000," Hughes said.
Some local officials ask ambulance services whether they could move to a volunteer system. Recruiting reliable volunteers, though, proves more challenging each year, with busier family lives and a tough economy forcing workers to focus on their jobs.
"We get lots of four-hour calls," said Morgan County paramedic King. "It's hard to talk your boss into letting you leave for half a day."
Ambulance companies will consider linking themselves to a local property-tax mill levy, as many fire districts do. Those revenues are endangered, though, by falling property values in the recession. Many counties are bracing for large budget hits after their next valuation cycle.
"It's a rough time to go out and ask folks to raise taxes," said Summit County manager Gary Martinez.
Still, Martinez said, the county is committed to emergency services for both residents and visitors.
"It's vital we provide excellent services for the guests who come to Summit," he said. "It's important on a personal level as well as a business level."
Morgan County and other counties, Walter said, will have to ponder in the coming months what service they expect at the next crisis.
Do you want an ambulance, Walter asked, "that will bring the emergency room to you? Or one that will just give you a ride to the emergency room?"