Access to Emergency Medical Services Education: A Case Study of the Unique Regulatory Structure in Georgia

Janet Fraser, PhD, EMT-B, West Virginia University, Department of Management Information Systems

Alicia Plemmons, PhD, West Virginia University, Department of General Business

Abstract

The location and development of training facilities for medical practitioners are crucial for labor market access and consumer access to critical healthcare services. While national studies exist, many states within the U.S. have Certificate of Need laws for emergency medical services which allows competition to directly influence the approval and location of new facilities. Georgia has a unique regulatory environment that has never been subject to these restrictions within EMS. We provide a descriptive analysis of medical education facilities and program access when location decisions are determined only by socioeconomic and demographic factors.

Keywords: emergency medical services, occupational licensing, healthcare access

JEL Classification:I18, I20, R41

Introduction

Emergency medical services (EMS) are a critical component of public safety services alongside police and firefighters. Access to quality EMS can be the difference between life and death in some cases, but it all begins with access to EMS education. Access is rarely uniform, but existing studies have struggled to disaggregate the role of Certificate of Need (CON) laws and socioeconomic factors in influencing the geographic distribution of training programs and emergency medical services. We instead focus on providing a descriptive analysis of Georgia, as they have never had a policy where competition can directly influence the location of EMS facilities through regulatory procedures (CON laws), leaving only demographic items such as population density, education, and labor force participation as factors that may drive location decisions.

The credentialing system in GA follows the industry standard, there are three primary types of EMS providers: emergency medical technician (EMT), advanced emergency medical technician (AEMT) and paramedic.¹ Each of these provider types requires the provider to complete a specific educational program. Each provider type is more advanced than the previous, where emergency medical technician (EMT or, more specifically, EMT-B) is the most basic level of EMS provider, requiring a certification that can be acquired in as few as three months, while paramedic (also referred to as EMT-P) is the most advanced level of provider, requiring an associate’s degree.

There are 159 counties in Georgia, which was a major determinant when selecting this state for evaluation, as there is significant variability in the features of counties and training programs. With 159 counties, the sample size at the county level is substantial enough to support the use of regression models. Georgia also has a variety of rural and urban counties, 41 urban counties and 118 rural counties.¹

Figure 1 illustrates the number of counties and their highest level of EMS education available. Of note, there are 65 counties without any EMS education programs, 24 counties where the highest level of EMS education is EMT, 45 where it is AEMT, and 25 where it is a paramedic program. As cross-state travel to attend programs is cost-prohibitive for many people, the absence of a training program may be associated with reduced providers of a critical need service within communities.

Some counties have multiple EMS education programs, while others are desperately lacking. The counties with the most programs are Chatham (17), Fulton (18), and Cobb (20). Fulton and Cobb counties are in the Atlanta metro area, while Chatham County is where Savannah is located. And, as indicated previously, 65 counties have no EMS education programs of any type. Our explorative study provides a needed analysis of the physical proximity of healthcare service training when EMS is not subject to CON laws, allowing for future comparative studies.

Literature

Medical certification and licensure is a strict state government requirement where an individual must complete some combination of education and experience, examinations, displays of good moral character, and payment of several initial and continuing fees to be legally allowed to provide medical services for pay.² While most physician and non-physician roles are universally licensed through the United States, the scope of practice and tasks a prehospital provider may perform are determined by individual state legislatures. This difference is important when discussing access to EMS as the ability for EMTs, AEMTs, and paramedics to administer life-saving assistance such as naloxone, nitroglycerine, controlled pain medication, or other community-focused care may widely differ by location.³

Within each licensure system for emergency medical services, there are various types and levels of providers.^4,5 For example, Emergency Medical Technicians in Georgia must complete an approved EMT course and have proof of a current CPR certification. EMTs can only provide a limited range of services, such as working to stop bleeding, performing CPR and conducting emergency transport. Advanced Emergency Medical Technicians (AEMTs) complete additional education and are allowed to provide all the services of an EMT with the addition of providing fluids and administering a limited range of medications. Paramedics, who complete the longest and most intense training program, are capable of additionally providing oral and intravenous medication, monitoring electrocardiograms, and performing limited invasive emergency functions such as tracheostomies.

Spatial distributions of accredited training programs influence eventual access to resources, service providers, and the types of emergency care.⁶ If the spatial distributions are clustered within specific communities, but a far distance from communities in need, it may reduce patient access to care by restricting the labor mobility of EMTs, AEMTs, and paramedics to underserved areas, such as rural communities and areas with health professional shortages as they are operating in a fragmented state.⁷ Reduction in programs and access to care may increase wages and income for the limited number of service providers,^8,9 while also not increasing service quality,^10,11,12 and simultaneously increasing service costs.¹³

While there are national studies on the geographic distribution and access to paramedic and EMT programs and how they are influenced by population density,¹⁴ they do suffer from a severe limitation in that many states have Certificate of Need laws that prevent new training facilities and providers from clustering near each other or building services within locations where existing competition declares they are already able to meet the needs of the community.¹⁵

While Georgia does have CON laws for some specific hospital services, they are one of the few states that never had CON laws restricting where emergency medical transportation training facilities or service providers may be located. This means that there is no regulatory bias in geographic distributions, allowing for a clearer understanding of the role of other socioeconomic dynamics in location decisions such as race, education, population density, and access to major metropolitan areas.

Methods

This study aims to evaluate the number of emergency medical services training programs in different counties in Georgia. After reviewing the significance and correlation of different variables from the 2020 Census, the percentage of the population with a high school education and the percentage of the population in the labor force were found to be most significant drivers of EMS training facility location decisions. While there is some correlation between these two variables, it was felt that much of their effects can be differentiated.

The initial linear regression model takes the following form:

TotalPrograms = α + β₁PctHighSchoolGraduate + β₂PctLFPR + β₃PopulationDensity

+β₄DistanceAtlanta + ϵ(2)

The dependent variable of interest, TotalPrograms, represents the total number of EMS education programs located within a county. PctHighSchoolGraduate is the percentage of a county’s population with at least a high school education as reported by the 2020 U.S. Census. PctLFPR is the labor force participation rate for civilians between the ages of 16 and 64 as reported by the 2020 U.S. Census. PopulationDensity and DistanceAtlanta are the population density and the distance of the county to Atlanta, respectively.

The lack of significance of the variables in the linear regression model, except for the population density, led to further investigation of the data structure and a pivot in methodology, though the core variables remained the same in the later models.

Figure 3 illustrates the county of counties with each distinct number of programs. Note how 65 counties have zero EMS training programs, suggesting that it could be difficult to get access to an EMS

training program in much of the state. Meanwhile, 24 counties have one training program, 33 counties have two programs, and 11 counties have three programs. The mean and variance of the total number of programs were also compared and found to be substantially different, with a mean of 2.1195 and a variance of 11.2958, suggesting that a negative binomial regression model would better fit the dependent variable.

The negative binomial regression models evaluates the total number of EMS education programs in each county. The first two models considered high school graduation rates and labor force participation rates separately and the final model considered high school graduation rates and labor force participation rates together with population density in each county and each county’s distance to Atlanta, as proxied by Fulton County.

log(TotalPrograms) = α + β₁PctHighSchoolGraduate + β₂PctLFPR + β₃PopulationDensity

+β₄DistanceAtlanta + γTotalPrograms + ϵ(2)

Results

Table 1 illustrates the results of the four models used to evaluate the number of EMS education programs in each county in Georgia. The linear regression model, within column (1), does not show any significant relationships, except for population density, as statistically significant predictors of EMS education programs. However, after reviewing the distribution of the data and comparing the mean and variance, a negative binomial approach emerged as a better fit to the data and three negative binomial models were tested in columns (2)-(4).

Prior studies found population density is an indicator of access to EMS but did not consider access to EMS education. The results of this study suggest that socioeconomic factors, such as the percentage of the population with a high school education and the percentage of the population in the labor force, influence access to EMS education. The final model, with both socioeconomic variables, does perform better than the models that look at high school education and labor force participation individually but it is clear there is some correlation between these predictor variables. It is important to note that as the rate of high school education attainment increases and as labor force participation increases, so does the number of programs in a county.

Conclusion

Medical certification and licensing is a distinct regulatory institution where state legislatures determine both the requirements to qualify for a license within their state and what tasks and duties are within the practitioner’s scope of practice. Types of licenses can vary greatly depending on the levels of education, experience, continuing education, and fees an individual undergoes while in the application process. Historically, the exploration of access to EMS educational programs was biased by a regulatory structure where competition can directly oppose new facilities entering the market. Georgia is an interesting case study for understanding where medical institutions would be located without this regulatory restriction, providing crucial insight to future comparative studies.

This study explores the drivers of geographic distribution and access to emergency medical services as proxied by the location of EMT, AEMT, and paramedic training programs in Georgia during 2021. Focusing on Georgia is a crucial contribution to the literature because while national studies do exist, several states have Certificate of Need laws that affect where training programs and emergency medical transportation services can be located which can be directly influenced by market competitors. While Georgia does have Certificate of Need laws for some facilities and services, they have never had limitations and competitor input into emergency medical services facility locations.

Using a negative binomial regression model, we confirm national findings that the location of educational programs is correlated with population density and can additionally analyze the socioeconomic factors of the communities. Both the education level and the labor force participation rate are positively associated with an increased presence of EMT, AEMT, and paramedic training programs, implying reduced access and resources for the most underserved and in-need areas. States, especially when re- moving Certificate of Need restrictions, should consider equitable access when developing new facilities and programs.

Appendix

Figure 1: Number of Counties and Highest Level of EMS Education Available

Figure 2: Map Depicting the Density of Training Programs

Figure 3: Distribution of County Counts of Training Programs

Dr. Janet Fraser is a Teaching Assistant Professor of Business Data Analytics at West Virginia University and EMT-B. Dr. Fraser’s research focuses on access to emergency medical services, intelligent transportation systems, and transportation issues in rural areas. Dr. Fraser has extensive experience teaching data analytics and deploying analytics to address real-world challenges.

Dr. Alicia Plemmons is a Research Fellow and Coordinator of Scope of Practice Research in the Knee Center for the Study of Occupational Regulation at West Virginia University. Dr. Plemmons’ research uses applied spatial and econometric methods to determine how policy changes affect labor markets by studying how to create environments that facilitate healthy economic growth and business development through research into the determinants of entry, operation, and exit decisions of firms, laborers and consumers. Her work on medical licensure and certificate of need laws has been featured in several news outlets and she is regularly asked to provide professional testimony on occupational licensing for both state and federal legislatures. 

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