It’s Time for an EMSCorps

The photo shows the Star of Life.
File Photo

Daniel R. Gerard, president of the International Association of EMS Chiefs, has some thoughts on rebuilding EMS.

For decades, EMS leaders have warned of the challenges of recruiting and retaining staff. The pressures associated with responding to a pandemic with an advanced response posture would be untenable for organizations for a month, but many maintained this stance for over two years. COVID highlighted the vulnerabilities within EMS, but none more daunting than the workforce, and it played out for the world to see.

No one calls 911 and states: “I live at 186 Harrison Street, my mother is having a heart attack, please get here right away…oh and send the two best people you have.” That is the public’s expectation. Yet we are fielding people who are overworked, tired, under-paid – and sometimes we fill the seat with whomever will take it. We have EMTs and paramedics who can  have four jobs to make ends meet; who live at home with their parents because they can’t afford to live on their own; who are on food stamps because they cannot feed their family; and in some instances, resort to using OnlyFans to pay their bills because they have no other choice.

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EMS departments regardless of service delivery model cannot attract people to work for them. People are leaving the profession in droves. For decades EMS has lagged behind the fire and police services regarding compensation. We can’t expect people to come here without creating jobs that provide them with a salary that makes it worthwhile for them to stay. The two most important questions become first how do we rebuild, and second how do we address the underlying issues?

Early Attempts to Rebuild

In 1973, President Nixon signed the Comprehensive Employment and Training Act (CETA)1, and later on in 1990, President George H.W. Bush signed into law the National and Community Service Act2, (AKA AmeriCorp which is still in existence). Both of these programs placed EMTs throughout the United States.

EMSCorps

Every time we lose someone who decides that they cannot make it here because they are struggling, we not only lose the clinical expertise that is critical to reducing death and disability, we lose the institutional memory that is crucial for maintaining our systems and developing the next group of EMTs and paramedics. Would establishing an EMSCorps be a viable solution to train and place EMTs and paramedics across the U.S.? Would it provide a fair salary, benefits, and education – all part of a larger jobs program to stimulate the economy?

Senator Bernie Sanders has introduced the Emergency Medical Services Staffing and Support Act.3 If signed by the president, it would authorize and appropriate $500 million to establish a program within the Health Resources and Services Administration (HRSA) to provide grants for local EMS organizations. The program would support funding for EMS responders through the purchase of equipment, improving the well-being of personnel, bolster recruitment, develop planning for long term staffing, build station facilities, provide education and training. These are the essential elements that many EMS organizations struggle with.

This is an excellent piece of legislation and a crucial first step in supporting EMS in the U.S. This program will benefit public and private providers of EMS, small rescue squads, third service departments, hospital-based systems, municipal/county contracted providers, volunteer, career, rural, big city, they would all be eligible to receive this money.3

Staffing and recruitment are key pieces of this legislation. The next question is: how do we get people to stay?

Salary and Benefits: Addressing the Elephant in the Room

The Act, if implemented, would serve as the conduit for an anemic EMS employment field, but how do we finance long-term pay and benefits?

The U.S. healthcare system is a bundle of contradictions, confusing to academics, policy-makers, insurance companies, and to the very people who must provide it. It is so complex in its formulation, it defies description. The costs associated with providing healthcare have skyrocketed approximately 150% over the past four decades. The share of the gross domestic product allotted to health care has increased from 7.2% in 1970 to 17.7% in 2018.4-6,10,14 EMS (exclusive of emergency department care) accounts for only a fraction of 1% of the total GDP spent on healthcare in the United States.

(Note: There are no concrete numbers for utilization and cost relevant to the GDP in the United States regarding emergency medical services. The estimate of a fraction of a percentage is determined based on the current GDP for healthcare in the United States ($2.9 trillion dollars) and utilizing the CDC’s National Ambulatory Medical Care Survey (NAMCS) survey tool. There were 136,000,000 emergency department visits in the United States in 2014, 15% arrived via EMS. Using 20.4 million (15% of 136,000,000) as a baseline number and multiplying that via the CMS fee schedule for an ALS1 response yields $6.6 billion dollars in revenue. The ALS1 rate was chosen because while the overwhelming majority of patients are transported utilizing basic life support, this figure does not account for mileage or those patients treated at the higher ALS2 rate (using CMS data approximately 3.6%). This figure does not take into account patients who were treated/examined and left at the scene, nor does it account for the confounding variable in cost for volunteer versus career (paid) services.)

We have increased demand for service and very little money is coming our way to increase capabilities and capacities. This is not a model for economic success. Yet covering the cost of the proviso of EMS across the US does not follow any logical pattern, it is a Rube Goldberg contraption more doomed to failure than success.

Communities across the United States have failed to finance EMS as an essential component in the public safety triad or the emergency healthcare system.7 Until we address this issue, any attempt at discussions regarding equitable pay and benefits for EMTs and paramedics are moot – we cannot pay for something we don’t have the money for and we cannot bill our way out of this mess.

What makes EMS a different animal when compared to other healthcare entities? EMS is an inclusive system of care: your insurance status doesn’t matter; if you do have insurance we don’t care who provides it. We deliver service 24 hours a day to anyone who calls, because most importantly EMS by its very definition and provision is a public good.13 We ensure access to anyone, the same way we do for police and fire service, but for some reason we fail to treat EMS as a public good.

Hospitals bill for service and they are able to pay their staff fair salaries. Healthcare systems have the ability to access revenue for uncompensated care from the state and federal government; they can leverage the administrative costs for Medicaid to supplement what Medicaid re-imburses them for providing care; and they can offset costs between different parts of the hospital that produce more revenue than others. EMS doesn’t have that same level of resources and we cannot offset our costs from one revenue stream to another when our patient population is indigent.

We cannot continue to finance the EMS system as it stands. EMS is the healthcare provider of last resort for these most fragile members of society. Yet they are the ones we hold responsible to fund the service across the U.S.4-7 Since the dawn of EMS, with very few exceptions, no community has fully funded their EMS system.8 Instead we are asking the destitute, the old, the socially deprived to fund the system. It is this hodgepodge of billing designs that results in low pay and benefits packages across the United States.

If we raise the Medicare rate and a department charged $2,000 for service, Medicare pays 80% of that, the patient will still have to pay 20% – $400. For patients on Medicare who are living month to month, who does this benefit? For many of them they are making hard decisions about food, rent, and which medications they can afford to take. Now we saddled them with a bill for $400.

We treat EMS as a profit center instead of a cost center, and this has been one of our greatest problems. From the time they were implemented Medicare and Medicaid were never meant to cover the full cost of EMS.6,7,9-12 They were strictly designed to re-imburse services for the cost associated with transport to a medical facility. The expectation always was that communities would fund EMS services the same way they funded police and fire services.

The Emergency Medical Services Staffing and Support Act is an excellent step toward shoring up EMS, but when the grants expire, what are we left with? Local communities need to stand up and fund EMS in the same way they fund police and fire services, instead of these various schemas aimed at improving revenue that fail to pass the sniff test. Payer mix’s, call volume, demographics, poverty and income all affect an organizations ability to generate revenue consistently. We have raised rates in the past for Medicare and there is a staggering difference in what some states re-imburse under Medicaid for EMS service.

When we have increased Medicare re-imbursement in the past,10-12,15-16 this money has never made it into the paychecks of the men and women who so valiantly do the job day in and day out. As various organizations go hat in hand to ask Congress and CMS to raise rates what is different now? You have to ask the question now we are going to pay a fair wage and benefits? What about the ambulances that need to be replaced, the rising cost of fuel, the increased cost of PPE, and the never-ending shortage of drugs? We are seriously going to improve re-imbursement so that we address all of these issues, not only the ones associated with compensation?

Why can’t a request for EMS be treated the same as any other 911 call for help?

You were robbed or your house catches fire, the police or fire department shows up. You don’t receive a bill.

You are having a heart attack, why can’t EMS just show up, provide care for you and transport you to a hospital without worrying about billing?

I applaud Senator Sanders for introducing the EMS Staffing and Support Act. We must do our part. Before the grants are instituted, before those grants expire, every community must make the hard decisions needed to adequately fund their systems of care. The career government officials, the elected and politically appointed leaders need to stand up and lean in. They must make the commitment not only to their community, and the patients who call 911, but to the very men and women who answer the phones, respond on the ambulance, and provide the care that saves lives.

This is our opportunity, not only to re-build EMS, but to become the first generation who solves this problem. Every community can show its support for the EMS Staffing and Support Act by enacting the mechanisms within their city, town, or village to bolster support for EMS by providing the same financial commitment to EMS that they do for police and fire services. Let our legacy be the generation that were brave enough to solve this problem instead of leaving it to someone else.

References

  1. Comprehensive Employment and Training Act https://www.congress.gov/bill/93rd-congress/house-bill/17526?s=1&r=5
  2. S.1430 – National and Community Service Act of 1990 https://www.congress.gov/bill/101st-congress/senate-bill/1430
  3. S. 3910: EMS Staffing and Support Act https://www.govtrack.us/congress/bills/117/s3910
  4. Cohen & Yu, Statistical Brief #354: The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the U.S. Population, 2008–2009 January 2012 Agency for Healthcare Research and Quality – Medical Expenditure Panel Survey https://meps.ahrq.gov/data_files/publications/st354/stat354.pdf
  5. National Health Expenditure Accounts, Centers for Medicare Services – https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html
  6. California Health Care Foundation Health Care Costs Accounted for 17.7 Percent of GDP in 2018 https://www.chcf.org/blog/health-care-costs-accounted-17-7-percent-gdp-2018/
  7. National EMS Advisory Council Committee Report and Advisory Current status: FINAL as of December 2, 2016 https://www.ems.gov/NEMSAC-advisories-and-recommendations/2016/NEMSAC_Final_Advisory_EMS_System_Funding_Reimbursement.pdf
  8. “Emergency Medical Services Systems Development. Lessons Learned from the United States of America for Developing Countries : Pan American Health Organization”, December 2003. Pan American Health Organization.
  9. Social Security Amendments of 1965: Summary and Legislative History https://www.ssa.gov/policy/docs/ssb/v28n9/v28n9p3.pdf
  10. Medicare Program; Fee Schedule for Payment of Ambulance Services and Revisions to the Physician Certification Requirements for Coverage of Nonemergency Ambulance Services https://www.federalregister.gov/documents/2002/02/27/02-4548/medicare-program-fee-schedule-for-payment-of-ambulance-services-and-revisions-to-the-physician
  11. Report to Congress Evaluations of Hospitals’ Ambulance Data on Medicare Cost Reports and Feasibility of Obtaining Cost Data from All Ambulance Providers and Suppliers As Required by the American Taxpayer Relief Act of 2012 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/Downloads/Report-To-Congress-September-2015.pdf
  12. Medicare Ambulance Payments a Framework For Change https://oig.hhs.gov/oei/reports/oei-12-99-00280.pdf
  13. Cowen, Tyler (2008). “Public Goods”. In David R. Henderson (ed.). Concise Encyclopedia of Economics (2nd ed.). Indianapolis: Library of Economics and Liberty
  14. “Spearheading EMS Transformation” EMS Insider, June, 2016 https://www.jems.com/ems-insider/spearheading-an-ems-transformation/
  15. Subpart B – Medical and Other Health Services § 410.10 Medical and other health services: Included services. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-410/subpart-B

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