“What if we can’t do this anymore?”
By KRIS B. MAMULA, Associated Press
The first responders’ biggest fear was realized one night in December when someone called 911 for help in rural Erie County and nobody came.
The first dispatch went to Union City Fire Co. When Union City couldn’t crew its ambulance, the call rolled over to neighboring Waterford Volunteer Fire Department.
Waterford couldn’t raise an ambulance crew either, so the call went to nearby Mill Village Volunteer Fire Department. Again, no answer.
Fifty-one minutes later, the county 911 center canceled the alarm, saying the caller was going to the hospital in a private vehicle.
“It’s here,” a somber Union City Fire Chief Isaiah Edwards told his firefighters a week later at a station meeting. “We’re dropping a ton of calls. It’s going to be a mess. I don’t have answers.”
Whether such dropped calls have resulted in a death in Erie County is unknown, but rescuers say it’s their biggest fear. And Union City isn’t alone.
Problems recruiting first responders, rising operating costs and Medicare reimbursement that hasn’t kept pace with expenses are stressing emergency medical services throughout rural Pennsylvania.
The County Commissioners Association of Pennsylvania calls EMS problems a crisis and has made it a legislative priority. The Erie Area Council of Governments has been meeting with fire chiefs and EMS officials for the past year to better understand the scope of the problem in Erie and Warren counties — an area 44 times the size of Pittsburgh.
Both agencies say solutions may be years away. Union City firefighters say they may have months.
“What if we can’t do this anymore?” Edwards, 31, a heavy equipment operator, asked the firefighters. No one answered.
During the 1970s and ’80s, emergency medicine rendered by trained personnel from rolling intensive care units became a standard of care in saving lives.
Seeds of the recent crisis were sown as insurers’ payments for emergency care began to lag behind the rising EMS operational expenses. “The financial situation of the state’s EMS agencies is a key reason for the ongoing declining number of agencies,” a 2018 state Senate report concluded.
Outside of bigger cities like Pittsburgh, emergency medical service is not supported by municipal tax money. That leaves the vast majority of nonprofit ambulance services reliant upon billing for care to keep their trucks on the road and staffed around the clock.
Medicare pays ambulances and other medical providers according to a set payment list, said Dom Pascucci, health insurance specialist at the Wexford offices of broker Emerson Reid.
“Most ambulance services don’t even negotiate with commercial carriers,” Pascucci said. “It’s take it or leave it. And if you accept Medicare, you can’t balance-bill” or ask the patient to pay an amount not covered by Medicare.
To set its rates, Medicare is surveying a number of ambulance services to determine average costs. Hospitals are required to file cost reports for providing various services. Medicare payments are typically based on a percentage of costs, with hospitals generally receiving 12%.
Because Medicare payments haven’t kept up for ambulances, some experts say tax support may be the only solution to guarantee first responders show up when someone dials 911.
“People need to treat EMS more like they do water, sewage and garbage,” said Eric Henry, owner of Meadville Area Ambulance Service and newly elected Crawford County commissioner. “Nobody pays for EMS.”
‘No time to help out’
Last year, Union City couldn’t muster an ambulance crew for 200, or 28%, of the 710 total calls received. Even if the fire company answered every call, experts say the volume is barely enough to break even financially — a common story in small towns around the state.
As a Band-Aid, Union City hired two EMS responders a year ago, who double as firefighters. Union City Borough makes annual donations of $24,000 to the fire department, which is about one-third of the $75,000 needed for the two paid employees.
Union City’s service is augmented by a private service, which charges between $150 and $200 per call, depending on the level of care provided.
The EMS math tightrope is similar across many such services in Western Pennsylvania.
Most of Union City’s ambulance patients have Medicaid or Medicare insurance coverage — typical for EMS services — which pay $160 and about $400 per call respectively.
A new ambulance can cost between $150,000 and $200,000. And new power stretchers — which help load overweight patients while cutting worker’s compensation injury claims — cost between $60,000 and $70,000 each. The latest heart monitor costs about $90,000.
Larry Obert is among the Union City EMS volunteers. He’s 79 and believes tax support is the best long-term solution.
“It’s a nightmare,” Obert said. “Somebody has to subsidize it.”
At the January meeting of Union City firefighters, Obert made a motion authorizing the fire chief to ask borough and township officials to come up with the funds needed to hire an eight-person EMS crew for around-the-clock protection. Preliminary figures put the payroll costs at $326,000 a year.
If the municipalities balk, Union City would begin winding down its EMS service by June. A previous volunteer ambulance service shut its doors in 2015 and the fire department created a new service a year later.
Raising the municipal donation is out of the question without a tax hike in a part of rural Pennsylvania that’s already stressed, borough council President Dan Brumagin said before the firefighters met.
Union City, 22 miles southeast of Erie, is a manufacturing town of about 3,200 people that lost its 35-bed hospital and newspaper years ago. Brumagin said the borough is among the poorest communities in the county.
“If we have those kinds of services, it would definitely mean a rate increase,” he said. “We’re not Philadelphia; we’re not Harrisburg. It’s a huge, huge problem.”
Questions about the future of Union City’s ambulance service arose as the fire department made plans for its annual membership drive, which launches in April for the year starting in July. Selling memberships is a way EMS agencies raise money for uniforms, stretchers and ambulance repairs.
Union City’s annual subscription costs $40, but this year’s signups were trailing last year’s count, said Shirley Lafferty, fire company treasurer.
An ambulance subscription keeps patients from having to pay the full balance of the bill remaining after payment by the health insurer. Many households pay for a subscription that is never used.
Union City wouldn’t be alone if it were to fold. Between 2012 and 2018, the number of EMS agencies statewide fell 22% to 1,278, according to the state Senate report.
When small EMS agencies like Union City can no longer answer calls, bigger, private services with all-paid crews have been quick to step in. Consolidation can mean improved medical care and operational efficiencies.
But experts say big ambulance services aren’t immune to the forces threatening emergency services. Pittsburgh EMS, for example, answers some 64,600 calls a year, yet is expected to run an $11.4 million operational deficit in 2020. Tax money will make up the shortfall.
Fayette EMS, a nonprofit service that answers about 24,000 calls annually from a rural, 798-square-mile service area, has managed to avoid operating deficits, but only with municipal support.
In April, Fayette EMS notified elected officials in Farmington that it was closing its station there — the fourth station to close in seven years — because the number of calls wasn’t enough to cover overhead expenses.
About 100 calls a month are needed for a station to break even; the Farmington station had between 50 and 60 calls, said Fayette EMS Chief of Operations Rick Adobato.
The community balked at the planned closure.
The result was $125,000 in municipal and other donations to keep the station open for another year. Adobato is banking on county funding in future years to keep the station viable.
“We’re going through hell right now,” Adobato, 65, said. “We’re just trying to hold it all together.”
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