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  • 18 Jan 2023 3:51 PM | Matt Zavadsky (Administrator)

    Thanks to EMS1 for publishing this overview of the NAEMT Workforce Survey.

    Click here to view the full NAEMT 2022 National Report on Engagement and Satisfaction in EMS survey report.


    The EMS workforce: Critical condition!

    Why right-sizing EMS response is crucial to increasing pay and improving work-life balance

    "As the respondents to the [NAEMT survey] clearly state, this is not purely a pay issue – it’s a combination of hard work-life balance, economics, leadership and culture," write the authors.

    By Matt Zavadsky and Robert Luckritz

    Jan 4, 2023

    The National Association of Emergency Medical Technicians’ 2022 EMS Worker Engagement Survey should be a Klaxon for EMS and community leaders across the country. This report is a treasure trove of insights that, on the one hand, may not be terribly surprising to most EMS leaders; but on the other hand, may dispel some myths and urban legends about what EMS leaders think their practitioners want.

    Here are the top 5 things we feel are most revealing about the report.

    "As the respondents to the [NAEMT survey] clearly state, this is not purely a pay issue – it’s a combination of hard work-life balance, economics, leadership and culture," write the authors.


    Only 32% of the survey respondents agreed with the statement “Management provides clear and consistent information to personnel.” We get it, EMS systems often scatter personnel across geography and the clock, but we have to find a way to communicate, really communicate with our workforce.

    Email is easy, but ineffective and impersonal. Perhaps the first step to improving effective communication is to ask what methods of communication your employees would prefer, and then do that.

    At MedStar, we have an employee-only social media platform that helps foster interesting communication processes. We also conduct monthly virtual Town Hall meetings that are video recorded and distributed to all employees.

    At Austin-Travis County, we conduct biweekly Chat with the Chief podcasts to relay the latest department information. Employees are encouraged to submit topics and questions that the Chief answers, regardless of how delicate or controversial. It’s critical to be willing to discuss difficult topics.

    Implementing structured rounding tools to track leadership interactions with front-line employees eliminates unconscious bias and ensures all employees are getting a chance to interact with leadership. The most time-consuming, but most effective thing EMS leaders should do is go visit the employees, in their offices. That may be a station, it may be the cab of an ambulance at a post location, whatever! Go to them, sit in the dayroom, stand in the parking lot of the post location, and listen to what they share with you. What do they enjoy about their job? What drives them crazy?

    What can you and the agency do better? They will rarely come to you with that information, but when you’re in their environment, you’d be surprised how open they tend to be.


    When asked to rank “Management provides regular constructive feedback on my overall performance as an employee” and “My agency provides easily accessible patient outcome information to its EMS practitioners,” 48% of the survey respondents disagreed, while only 28% agreed.

    Today’s workforce needs lots of feedback. A recent study cited in an article by Inc. found that 66% of Gen Z say they need feedback from their supervisor at least every few weeks to stay at their job. Similarly, EMS practitioners want to know how their patients did after they cared for them. This is due to the deeply rooted desire to make a difference with their actions. EMS leaders need to find a way to deliver feedback at least monthly to their employees – this could be through specific metrics that the employee can access or a push notification about some aspect of their performance (patient experience scores, clinical bundle compliance, anything!).

    One high-performance EMS agency positions a supervisor in their deployment center to literally touch base with every crew member before they go out for their 12-hour shift, just to say “hi,” address them by name, smile and ask if they need anything for their truck, did they get water, etc.

    Medical oversight departments should automate processes that link EMS patient charts to hospital data so crews can log in to a prior EMS chart and review the outcome fields (e.g., admitted, discharged, deceased, etc.). This will not only improve employee satisfaction, but also allow crewmembers to do some self-analysis, and help them feel more like they are a part of the patient care team for that patient.


    Not surprisingly, the lowest score from the respondents to the engagement survey related to pay and compensation. Sixty-three percent of respondents indicated they disagreed with the statement, “My pay and benefits are adequate and appropriate for the work I perform.” The economic model for EMS is challenging. Revenue is derived from two sources, user fees and public funding. For EMS agencies to be able to increase pay rates, those two funding sources must support the expense. Fee for service reimbursement has been static, if not decreasing, at a time when expenses for personnel, equipment and supplies are skyrocketing.

    Thankfully, some states and local communities have recognized the need to increase compensation for EMS providers and have provided supplemental funding to support increased pay rates. EMS leaders need to get serious (and creative) about finding ways to increase compensation for EMS practitioners. You can seek additional funding by either increasing reimbursement (Medicaid rate increases), or convincing local elected officials that additional tax support is needed.

    You can also consider EMS delivery re-design, such as tiered (BLS & ALS) deployment, changing response time goals, or alternate response models (e.g., medic only, RN/NP only, medical first response only) for low-acuity calls. This would reduce staffing needs while having minimal impact on revenue. The financial savings can be used to increase wages for EMS practitioners.


    When asked why they were leaving EMS, 50% of the respondents said, “Better work-life balance.” Yes, EMS is a 24/7 operation, and someone will always have to work nights and weekends, but the problem is more deeply rooted. Due to staffing shortages, many agencies are mandating overtime to achieve optimal coverage, while many EMS practitioners are working two or three jobs to make ends meet due to the low pay. Those extra jobs tip work-life balance to the point people become dissatisfied and leave EMS. It’s almost a self-fulfilling prophecy. Practitioners leave, which means others in the agency must work extra shifts to fill the void. That, in turn, leads to dissatisfaction with work-life balance, causing EMS practitioners to leave, which causes ... well, you know!

    EMS leaders should work with practitioners to create schedules that A) meet the agency’s needs and B) allow the employees some work autonomy and balance. MedStar allows select EMTs and paramedics to self-schedule. As long as the employee meets certain eligibility and schedule requirements, they pick their shifts. This helps with retention of folks that may have left for work-life balance.

    System redesign isn’t just about economics; it affects work-life balance as well. Shifting to a tiered system changes staff workload and work experience by different levels of providers and can also extend careers by providing a better career ladder for providers. Shifting staff to alternative resources to address high utilizers and provide alternatives to EMS transport relieves the workload on transport providers. We can’t be afraid to reimagine our systems. Systems need to look at staff resources, and if they aren’t necessary at a certain time, be willing to shut them down. Employees don’t want to be mandated in, even on overtime.

    At Austin-Travis County EMS, we began electing not to staff some ambulances instead of mandating overtime, and have seen a minimal impact on system performance when done with a strategy in mind. Employees that are working would rather spend time during their shift moving and ensuring coverage than being mandated in.


    The EMS staffing crisis was looming for years; the pandemic merely accelerated the inevitable. A perfect storm of changing workforce expectations, with employment needs across healthcare and many other sectors is exacerbating the crisis. As the respondents to the survey clearly state, this is not purely a pay issue – it’s a combination of hard work-life balance, economics, leadership and culture.

    It’s up to us to dig ourselves out of the hole we’ve dug. Employees need to be put first, not last or even second. No EMS system can survive, no matter how advanced, without an engaged workforce. EMS delivery needs to be totally transformed away from a “you call, we haul” model to a “you call, we navigate” model. We need to take a hard look at long-held preconceptions about things like ALS staffing, response times and throwing everything, including the kitchen sink, to every EMS call. We need to seriously reduce workloads, and the resulting costs of readiness, based on processes that are not supported by evidence-based research.

    Community partnerships with clear, transparent and frank conversations about community expectations and costs of service delivery need to be held with local stakeholders. If we are successful at right-sizing responses, we just might be able to increase the value of EMS delivery with a reduced workload – allowing us to increase funding and reduce costs. Then, we may be able to help EMS practitioners achieve a better work-life balance, and increase pay rates.



    Robert Luckritz is the chief of Austin-Travis County (Texas) EMS. He has more than 25 years of experience in EMS and healthcare, serving as an EMS provider, EMS leader, attorney and healthcare executive. Rob is also the treasurer for the National Association of Emergency Medical Technicians (NAEMT) and chairs its Workforce Committee.

    Matt Zavadsky is the chief transformation officer for MedStar Mobile Healthcare, the Public Utility Model EMS system serving Fort Worth, and 14 other cities in Texas. He has 43 years of experience in EMS. He is an at-large director for NAEMT and chairs its EMS Economics Committee.

  • 9 Jan 2023 6:25 PM | Matt Zavadsky (Administrator)

    Aspirational for the U.S.?

    The Scottish Ambulance Service is part of the National Health Service (NHS).

    You might also be interested in their 2021-22 OOHCA stats:

    • 66% Bystander CPR Rate
    • 8% AED use prior to EMS arrival
    • 10% survival to discharge rate


    Nearly 50% of 999 calls being managed out with Emergency Departments

    December 22, 2022

    The Scottish Ambulance Service is managing nearly 50% of the 999 calls it receives without the need to take patients to Emergency Departments across Scotland.

    Latest figures for the Scottish Ambulance Service (SAS) in October 2022 show that the proportion of patients being cared for out with Emergency Departments was 49.1%.

    This was made up of 24.9% of patients who were managed at the point of call and a further 24.2% whose care was managed by SAS clinicians on scene.

    These results have been achieved through a range of initiatives, including working closely with partners to increase the range of alternative clinical pathways in communities which support the Service to deliver care closer to home, accessing  Health Board Flow Navigation Centres, expanding our Mental Health pathway access, and utilising highly-trained staff in remote clinical consultation and assessment. The Service’s central Pathway Navigation Hub also continues to increase the volume of calls it manages, connecting patients with services and communicating pathway information to SAS clinicians.

    The figures are released as the Service launches its Integrated Clinical Hub, coordinated through the SAS Ambulance Control Centres in the west, north and east of Scotland. Health secretary Humza Yousaf visited the Service’s East ACC base today in South Queensferry to meet SAS Chief Executive Pauline Howie and Chair Tom Steele, along with key staff involved in the Integrated Clinical Hub. The Health Secretary also thanked staff for their dedication over the past year.

    Using a multi-disciplinary network of skilled clinical staff across Scotland, the Hub gives SAS the ability to provide a detailed consultation for patients whose initial 999 triage has ruled out time-critical illness. The hub will operate 24 hours a day, to ensure patients receive the best possible response to their need when they dial 999.

    SAS Chief Executive Pauline Howie said: “The number of patients being cared for out with hospital Emergency Departments remains substantial and as we head into a challenging winter period, it’s vital we work together with our health board and community colleagues to find ways of delivering the right care for individuals and easing pressure on Emergency Departments. We are focused on continuing to develop our clinical care model to support more patients in communities where it is safe to do so and to ensure patients get the right care, at the right time.

    “The clinical decision-making roles within our Integrated Clinical Hub all have a role to play in understanding patients’ need at point of call, and that they receive the most appropriate care and support to ensure there is a positive impact across the whole system.

    “If the patient’s symptoms are not immediately life-threatening, they can then benefit from a clinical assessment with a senior experienced clinician to agree how help can be best provided. Frontline emergency clinicians can also be supported by more senior clinical staff via telephone and video, aiming to enable the patient to access the most appropriate pathway or care provision to address their need. This can help reduce pressure within Scotland’s Emergency Departments.

    “To help our staff, we also would like to remind people that if you need urgent care, but it’s not life-threatening, you can call NHS 24 on 111, day or night, or your GP during opening hours.”

    Health Secretary Humza Yousaf said: ““We are facing a challenging winter ahead for the NHS and its initiatives such as the integrated clinical hub that can help ensure patients receive appropriate care at home or in the community and alleviate pressures on our already busy A&E departments.

    "There are a range of pathways of care and not every call to 999 needs an ambulance or a trip to A&E as demonstrated by stats out today.  Experienced clinical staff are on hand to triage calls and get patients the right care at the right place. Once again, I would like to thank Scottish Ambulance Service staff for their tremendous work and dedication.”

  • 4 Jan 2023 1:02 PM | Matt Zavadsky (Administrator)

    We did a fact check with John Peterson, the Executive Director for MEDIC on this statement in the article –

    Peterson said less than 1% of Medic’s 13,000 calls in the past year required patients to be transported as high-priority.”

    John stated that less than 1% of their SIERRA protocol 911 calls receive a high-priority transport. 

    MEDIC’s SIERRA protocol is their 9-1-1 ALPHA and OMEGA emergency medical dispatch response determinants that have a response time goal of 90% in under 60 minutes.


    Calling 911 in Charlotte? Your ambulance might show up without lights and sirens.


    DECEMBER 14, 2022

    Medic told county commissioners Tuesday about a plan to use lights and sirens less often.

    Mecklenburg’s EMS agency is proposing a quieter, dimmer and slower way to get some patients treatment in the new year. Medic on Tuesday proposed to county commissioners decreasing lights and siren use from 76% to 19% of 911 responses. That means limiting use to life-threatening situations such as anaphylactic shock or a gunshot wound. The change is expected to occur in the first quarter of 2023.

    Medic Executive Director John Peterson said many responses originally labeled life-threatening, with ambulances using lights and sirens, end up not requiring transportation to a hospital.

    Lights and sirens can get first responders to a patient between 42 seconds and 3.8 minutes faster than without them — enough time to save a life in a potentially deadly emergency.

    But Peterson said the saved time isn’t worth the crash risk if the patient’s life isn’t in danger.

    Using lights and sirens can increase the risk of traffic accidents by 50% according to a study by the U.S. Department of Transportation.

    Peterson said this often happens when a driver doesn’t see other drivers moving over for an ambulance or fire truck and tries to pass through an intersection on a green light like normal, resulting in a collision with the emergency vehicle.

    This year, Medic dispatched 76% of its total calls as life-threatening. Just 5% were determined to actually be life-threatening. Thirty-five percent of patients who called weren’t transported to the hospital at all.

    Mecklenburg County documents Commissioners asked how Medic determines whether an incident is life-threatening. Commissioner Susan Rodriguez-McDowell asked if pain is accounted for when determining dispatch speed.

    Medic representatives said first responders know the difference between injuries and are trained to respond based on notes from the initial call for service. “Fire units have the ability to upgrade calls and request lights and sirens if they feel that there is a medically necessary reason to do so,” Peterson said.


    Mecklenburg County will be the first in North Carolina to reduce its lights and siren usage in this way, Peterson said. Commissioners said they feared it will take time for the public to get adjusted.

    “When you’re in an emergency room, you can see other emergencies and you can physically see what’s more important and what’s more of an emergency than what’s happening to yourself,” commissioner Laura Meier said. “But when you’re calling 911, it’s an emergency to you.”

    Not understanding why a 911 response is taking a long time may result in unhappy customers, Meier said. Peterson said less than 1% of Medic’s 13,000 calls in the past year required patients to be transported as high-priority.


    One part of responses is how quickly dispatchers answer the phone — and Charlotte is responding below industry standard. Industry standard for 911 call centers is to pick up 90% of calls within 10 seconds.

    Right now, Charlotte-Mecklenburg Police dispatchers answer only 60% of calls within the time frame. In Charlotte, 10% of calls take longer than a minute to answer.

    CMPD’s call center shortages fit into a national trend, Deputy Chief David Robinson told the Charlotte City Council Monday. CMPD currently has 124 telecommunicators and needs 20 more to fully staff its call center, Robinson said.

    Robinson said CMPD is implementing the following measures to retain staff:

    • Increased hiring bonus from $2,000 to $4,000
    • Created additional promotion opportunities
    • 1% retention bonus for employees in July and September
    • 5% pay increase across the board week of Dec. 5
    • 2.5% shift differential for afternoon/midnight shifts Jan. 2023
    • 2.5% increase for secondary language
    • 4% salary increase Jan. 2023

  • 22 Dec 2022 9:42 AM | Matt Zavadsky (Administrator)

    Lots to unpack here – but some consistent themes have been emerging as hospitals and EMS systems are stressed during this triple-demic season –

    • The healthcare staffing crisis is impacting all providers, hospitals, EMS agencies and fire departments
    • Too many patients, especially low-acuity patients, are clogging EDs
    • The fundamental financial model for healthcare, including EMS, needs to change

    Notable quotes:

    • “The city has a goal for ambulances to respond to life-threatening emergencies within 10 minutes more than 90% of the time; it has only met that goal for one month since May 2021.”
    • “Pandemic-era staffing shortages in the fire department, which sends paramedics to the majority of medical emergencies, persisted. Making matters worse, the triple threat of winter flu, RSV and Covid packed some SF intensive care units near capacity this month.”
    • “An increase in the number of non-emergency cases coming to emergency departments and a lack of hospital space to take care of patients once they’re stabilized have also impacted ambulance wait times at ERs, according to Coleman.”
    • “We have to have a conversation about how we change health care financing to make the acute care system more resilient to these kinds of changes,” Janke said.

    We are blessed in MedStar’s service area, as our hospitals very rarely hold our units more than 20-30 minutes.  Potential reason? Recent data from our 2 largest hospitals, receiving hundreds of MedStar patients daily, 27% of the patients we bring in, go to the WAITING ROOM.

    We all need to be implementing changes that incentivize EMS to NAVIGATE 911 patients to the most appropriate medical resource.  Models like CMS’ ET3 work very well (we’ve navigated over 1,100 911 patients to resources other than an ED, but more agencies and communities should re-evaluate how they deliver services – it’s going to be a long winter!


    Why San Franciscans Wait So Long for Ambulances

    Written by Noah Baustin

    Published Dec. 20, 2022

    An ambulance crew picked up a young man on Dec. 6 who had probably overdosed on fentanyl. He wasn’t in immediate life-threatening danger, but he needed to see a doctor. The first responders drove the man to St. Mary’s Hospital and brought him inside.

    That’s when the waiting began.

    One hour passed. Then two hours were gone. Three hours came and went.

    The ambulance crew sat in the hallway with the patient on their gurney. Emergency calls continued to come into San Francisco’s 911 system but the ambulance couldn’t leave: the first responders needed to formally pass off care to hospital personnel.

    After four hours of watching a steady stream of walk-in patients get assistance, the hospital staff got to the man on their gurney. Four hours until they could respond to the next call for help in the city.

    It’s an all-too-common experience for ambulance staff working the streets of San Francisco.

    “[The hospital] shouldn’t have a higher priority than getting a patient off of our gurney so we can go back out and get patients who aren’t even at the hospital yet,” said Josh Nultemeier, King-American’s Chief Paramedic, who was not at St. Mary’s that day but oversees the crew and recounted their story to The Standard.

    Both the San Francisco Fire Department and private ambulance companies, such as King-American, respond to 911 calls in San Francisco.

    “We’re supposed to go out and pick up patients that are super sick with real emergencies that aren’t at a hospital yet. We’re being delayed from being able to do that,” Nultemeier said.

    Patients Left Waiting Too Long

    For the past year and a half, while paramedics have often been stuck sitting idle in ERs, San Franciscans having heart attacks, strokes and other medical emergencies have waited too long for an ambulance to show up.

    The city has a goal for ambulances to respond to life-threatening emergencies within 10 minutes more than 90% of the time; it has only met that goal for one month since May 2021.

    “It’s making people wait an unreasonably long time when they need help the most,” said Adam Wood, vice president of the San Francisco Firefighters Local 798 union.

    A perfect storm of problems has kept the city’s ambulances responding slowly. As Covid’s grip on the city loosened over the past year, crosstown traffic increased and the number of emergency medical transports to hospitals went up.

    Pandemic-era staffing shortages in the fire department, which sends paramedics to the majority of medical emergencies, persisted. Making matters worse, the triple threat of winter flu, RSV and Covid packed some SF intensive care units near capacity this month.

    But the most striking driver of ambulance delays is the jaw-dropping amount of time that crews spend in limbo at hospital emergency rooms, even as calls pile up in other parts of the city. Fire department ambulance crews sometimes wait three to five hours to pass off their patients, said SFFD spokesperson Capt. Jonathan Baxter.

    The amount of time between ambulance arrival at the hospital and ER staff taking over care of the patient, a metric called APOT, steadily climbed throughout the past year at all major hospitals in the city.

    Though city regulations state that hospitals should take ambulance patients within 20 minutes more than 90% of the time, none of the city’s largest hospitals hit that goal in a single month in the past year, according to records obtained from the SF Department of Emergency Management (DEM).

    In November, CPMC Van Ness’s APOT time was 61 minutes, triple the regulatory cap.

    “That’s too long, it should be faster,” said Dr. Alexander Janke, an emergency medicine physician and research scientist at the Yale School of Medicine with national expertise on how emergency rooms operate. “But it’s not surprising to me to hear these numbers, because I know how bad the bottlenecks are all over the country.”

    Short Staffing and Too Many Patients

    Local hospitals have struggled with the staffing problems that struck the industry nationwide in recent years. Limited staff and lack of bed availability can cause ambulances to have to wait to offload patients, DEM spokesperson Victor Wai Ho Lim said.

    The city’s eight largest hospitals all declined interview requests. St. Mary’s referred The Standard to the Hospital Council industry group, which represents SF’s public and private hospitals.

    “As evidenced during the Covid surges over the past three years, when patient utilization of emergency departments increases significantly, APOT events also increase,” Michon Coleman, regional vice president of the Hospital Council of Northern and Central California, said in a statement. “Hospitals are seeing an unprecedented volume of patients of all types and including Covid, flu and RSV, making achieving these targets more challenging.”

    An increase in the number of non-emergency cases coming to emergency departments and a lack of hospital space to take care of patients once they’re stabilized have also impacted ambulance wait times at ERs, according to Coleman.

    Hospitals across the country have run short on space this fall, a situation made worse by a nationwide whittling down of unprofitable pediatric beds over the past two decades and now apparent given RSV’s impact on young patients.

    But King-American’s Nultemeier believes that, to a degree, the ambulance backup has come out of a shift in how the hospitals prioritize patients.

    In the past, if a patient came to the hospital in an ambulance, they often got seen faster than if they arrived on their own, he said. Of course, patients experiencing potentially life-threatening emergencies have always taken first priority. But in recent years, the hospitals changed how they prioritize patients, placing more emphasis on clearing their busy waiting rooms than sending waiting paramedics back out to their ambulances, Nultemeier said.

    “It’s not an ambulance problem. It’s not a staffing problem,” Nultemeier said. “The hospitals don’t prioritize us dropping patients off and getting them off our gurney so we can get to the next call.”

    Kaiser-Permanente, however, didn’t point to any policy change as the reason for the hospital’s high offload times.

    “We have sufficient staff to care for our patients, but sometimes lack the physical space at the moment to offload the patient safely, and we will not offload a patient until it is absolutely safe to do so,” a Kaiser Permanente spokesperson said in a statement.

    Yale’s Janke said that the nation's emergency room backup crisis has been brewing for decades. Hospitals have a huge financial incentive to operate as lean as possible, having the minimum number of staff and beds possible at any given time. Inevitably, when the number of people getting sick spikes, the system isn’t flexible enough to handle the influx, like we’re having right now.

    “We have to have a conversation about how we change health care financing to make the acute care system more resilient to these kinds of changes,” Janke said.

  • 20 Dec 2022 9:53 AM | Matt Zavadsky (Administrator)

    With the announcement of the members of Advisory Committee on Ground Ambulance and Patient Billing (GAPB), PIRG released a report on ground ambulance balance billing.

    Download the PIRG Report here:

    The report acknowledges Arnold Ventures for its support.

    The author of the PIRG report is on the GAPB.

    The report has spurred media stories in the Washington Post and USA Today, included below. 

    No highlights in these, as all the content is important.


    Surprise bills from ground ambulances is next up in the move toward reform

    Ground ambulances were left out of surprise billing legislation. Experts will meet next month to consider how to wrangle them.

    Analysis by Rachel Roubein with research by McKenzie Beard

    December 13, 2022

    The Biden administration is set to kick off the work of a key advisory committee designed to help stop patients from getting hit with pricey surprise medical bills from ground ambulances, The Health 202 has learned.

    It took roughly two years for the new committee to get its start. But the panel’s meetings are now set to begin in the new year, with the first scheduled for Jan. 17-18. A critical report will be due 180 days later on how to prevent patients from owing hundreds of dollars for receiving out-of-network ambulance rides through no fault of their own.

    That’s according to a Centers for Medicare and Medicaid Services webpage detailing information about the advisory committee’s membership and its initial meeting, neither of which have been officially announced. CMS cites a Dec. 16, 2022, notice in the federal register, which suggests the information may have been inadvertently published early on the agency’s website.

    The upcoming launch of the advisory committee’s work is a step forward in fulfilling part of a law Congress passed in December 2020The legislation shielded patients from getting slapped with large bills when they unknowingly get care from an out-of-network provider, including for air ambulance flights. Yet, it didn’t apply to ground ambulances, instead mandating key federal departments appoint an advisory committee to recommend options for preventing such bills. 

    • “The ground ambulance loophole is a big gap that harms consumers,” said Madeline O’Brien, a research fellow at Georgetown University’s Center on Health Insurance Reforms. “We’ve been waiting almost two years for the committee to get off the ground and [are] very excited for the actions that they could be taking to protect consumers in this really critical space.”

    About the commission

    The details: The charter for the advisory committee was officially signed in November 2021, and the Biden administration began soliciting nominees to serve on the panel. 

    Roughly a year later, the committee’s membership is coming into focus. According to the CMS webpage, Asbel Montes will serve as the committee chair. He’s a managing partner at Solutions Group, which does health consulting and tech work, and leads the American Ambulance Association’s payment reform task force, according to his work bio. He referred The Health 202 to CMS for comment.

    • Committee members from the federal government include Rogelyn McLean, of the Department of Health and Human Services; Ali Khawar, of the Labor Department; and Tom West, of the Department of Treasury. 
    • Other members consist of a cross-section of the health industry, state and local government representatives, advocates and others. This includes Loren Adler, of the USC-Brookings Schaeffer Initiative for Health Policy; Adam Beck, of the major insurer lobby; and Patricia Kelmar, of PIRG, a public interest group.

    The view from CMS: In a statement, a spokesperson said the agency is looking forward to hearing the committee’s recommendations, which will help inform new policies aimed at “preventing balance billing, improving communication as it relates to insurance options for service, and by providing upfront and easy to understand disclosures of charges and fees for ground ambulance service.”

    State of play

    Ground ambulance billing is particularly complex. For instance, many emergency medical transport services are operated by municipal and county governments, and so they must adhere to state and local regulations. Meanwhile, some municipal services may not contract with private insurance companies, according to the Kaiser Family Foundation. 

    “The reality is there’s so much unknown that there’s wisdom to convening a panel of experts,” said Adam Buckalew, the founder of alb solutions who helped negotiate the surprise billing law as a GOP aide on the Senate health committee.

    The ground ambulance panel has been of particular interest to the House Education and Labor Committee.

    Chairman Robert C. “Bobby” Scott (D-Va.) and ranking Republican Virginia Foxx (N.C.) sent a letter, first shared with The Health 202, Friday afternoon urging HHS to “prioritize and complete its establishment expeditiously.” (The CMS webpage appears to be updated with information about the ground ambulance committee before the lawmakers sent their letter, though an Education and Labor aide said HHS had been alerted last month that the letter was coming.)

    Jamie Pafford-Gresham, the secretary of the American Ambulance Association, said patients should be protected from surprise bills, but a “balanced approach” to addressing the payment is needed. She contends getting it wrong could jeopardize access to emergency care, particularly in underserved areas.

    Onward: The report is just another step toward potentially banning patients from receiving surprise bills from ground ambulances. Congress will likely need to legislate in this space to make good on upcoming policy recommendations. 


    Half of ambulance rides yield surprise medical bills. What's being done to protect people?

    Ken Alltucker


    December 13, 2022

    When people dial 911, perhaps the last thing they think about is how much the ambulance ride will cost. 

    But a report released Tuesday by U.S. PIRG Education Trust shows ambulance companies routinely bill out-of-network charges. This happens when an insurance plan's network doesn't include the public or private ambulance company.

    Even after an insurer pays a portion of charges, about half of consumers are billed more. These extra charges add up to about $129 million each year, according to U.S. PIRG.

    Congress passed a law creating an arbitration process as of January 2022 to protect consumers from surprise bills during emergencies or when an out-of-network doctor provides care at an in-network hospital.

    The federal law, called the No Surprises Act, also protects consumers from costly air ambulance bills — but it doesn't address more common ground ambulance transports. 

    "This was the big gap in the No Surprises Act and it should be closed," said Patricia Kelmar, senior director of health care campaigns at U.S. PIRG Education Fund. "Three million insured people every year are going in an ambulance for an emergency, and half of those folks are exposed to a surprise bill."

    What to know about surprise ambulance billing 

    • Ground ambulances were excluded from the No Surprises Act in part because of the complex regulatory nature and large number of stakeholders. Ambulance companies are usually regulated by states and local municipalities.
    • About 51% of emergency ambulance rides included out-of-network charges that potentially exposed patients to surprise bills, according to Kaiser Family Foundation.
    • The median cost for a surprise ambulance bill was $450, a 2020 study found, but rates vary by state and region. The median surprise bill in Massachusetts and Minnesota exceeded $1,000 while California had the most expensive average bills at more than $1,200. 
    • Fire departments or other local government entities provided nearly two-thirds of ambulance rides in 2020 while private ambulance companies handled 30% of rides, according to Kaiser Family Foundation

    Do states protect consumers from ambulance bills?

    Ten states have laws to limit ambulances from billing patients beyond what their insurance companies pay, but those restrictions apply only to state-regulated health insurance plans and protections vary. For example: Maryland's protections apply only to publicly-owned ambulances and Colorado's prohibits private ambulances from such balance billing, according to the report.

    The states with protections:

    • Colorado
    • Delaware
    • Florida
    • Illinois
    • Maine
    • Maryland
    • New York
    • Ohio
    • Vermont
    • West Virginia

    A major loophole: State bans don't apply to most employer-provided health insurance plans, which are regulated under a Department of Labor law called the Employee Retirement Income Security Act.

    "That's why we really do need a federal law to make sure that all insured patients have protection from surprise bills," Kelmar said. 

    How is the federal government addressing ambulance billing?

    A federal advisory committee created by the No Surprises Act is set to meet in January for the first time. It then has 180 days to make detailed recommendations on fee disclosures and strategies to protect consumers from surprise buildings.

    U.S. PIRG recommends Congress amend the No Surprises Act to protect consumers from surprise ambulance bills. The federal law has prevented as many 9 million surprise medical bills through September, according to an analysis by Blue Cross Blue Shield Association and America’s Health Insurance Plans, a health insurance industry group. 

    Why consumers need protection

    Because people have no chance to compare prices or seek a better deal during an emergency, consumer advocates say it's unfair to stick patients with surprise bills. 

    "When you call 911, you don't know what ambulance is going to come," said Eileen Appelbaum, Co-Director of the Center for Economic and Policy Research, a progressive think tank. 

  • 20 Dec 2022 9:49 AM | Matt Zavadsky (Administrator)

    Perhaps a point for reference as EMS agencies across the county face ongoing fiscal challenges…

    Three of the most well-respected and successful health systems reporting record operating losses; Mayo, Cleveland Clinic and now MGB.

    Interesting that the insurers are simultaneously reporting record profits?


    Mass General Brigham says it's cutting costs, advancing integrated care after a financially devastating 2022

    By Dave Muoio

    Dec 19, 2022



    Mass General Brigham wrapped its 2022 fiscal year with a $432 million operating loss (-2.6% operating margin) and a $2.3 billion net loss, which the East Coast nonprofit system attributed to “historic cost inflation” and labor pressures as well as a volatile investment landscape.


    The numbers are a turnaround from the $3.2 billion overall gain MGB reported during the 2021 fiscal year. Operations that year brought in $442 million with the inclusion of $262 million in relief funding and risk corridor program subsidies; excluding those placed 2021 operating income at $180 million (1.1% operating margin).


    With continued operating challenges likely on the horizon, the health system said it is adopting new initiatives to ensure its business remains sustainable for the long haul.


    These efforts will focus on reducing expenses through administrative efficiencies “including eliminating vacant administrative positions,” MGB said in a release. The system will also build and support workforce pipelines to reduce its reliance on temporary staffing and push forward integration initiatives “including expanding home-based care and telehealth services to shift care beyond traditional hospital settings,” it said.


    “We are confident that thoughtful and strategic decision-making coupled with efficient resource management will enable us to continue investing in critical medical research, education and the communities we serve, while ensuring that we can care for every patient who needs us,” Anne Klibanski, M.D., president and CEO of MGB, said in a release


    MGB’s $432 million operating loss during the fiscal year ended Sept. 30, 2022, was largely comprised of a $395 million (-2.5% operating margin) loss from provider activity, which the system said reflected March’s omicron surge and other capacity issues. MGB’s insurance activity contributed the remaining $37 million loss.


    Total operating revenue for the year landed at $16.7 billion. Increased inpatient acuity and average length of stay brought discharges down 2% from last year and “curtailed” patient care revenue growth to 4% ($437 million increase). Staffing shortages among post-acute settings also limited discharges and pushed average length of stay to more than six days, roughly 15% longer than pre-pandemic.


    “The capacity crisis is not unique to academic medical centers, and all hospitals in the [MGB] system have been at, or above, 100% operational occupancy, on average,” the system wrote.


    MGB’s operating expenses increased by $1.6 billion (10%) over last year to $17.1 billion in 2022. This included a 9% increase in wages (which includes temporary staffing and wage adjustments), a 13% increase in employee benefit costs and a 13% increase in clinical supply costs.


    “Heading into 2023, we are employing strategies and tactics to address capacity challenges and ongoing inflationary pressures on labor and supplies costs, including a heightened focus on clinical integration to enhance patient care efficiencies and resource stewardship,” Niyum Gandhi, chief financial officer and treasurer at MGB, said in a release. “We have also prioritized engaging with Mass General Brigham’s leaders who are closest to the programs and services delivering care across the system to identify the most thoughtful and targeted approach to reducing costs.


    “Simultaneously, we are taking the next steps in transitioning our care model to one based on value rather than volume, facilitated by the launch of a zero premium Medicare Advantage plan, moving approximately 140,000 Medicaid members into a full risk program and demonstrating our commitment to improving the affordability of patient care,” he said.


    MGB said it absorbed $2.3 billion due to the difference between government reimbursement and care costs for Medicare, low-income and uninsured patients, a 15% ($307 million) increase over 2021.


    Nonoperating losses for the year were $1.8 billion, “reflecting heightened unfavorable volatility in the financial markets,” MGB wrote. These made up the majority of the system’s $2.3 billion annual net loss.


    “Healthcare is facing an unrelenting economic crisis that is impacting patients’ ability to access care. It is our responsibility at Mass General Brigham to continue to provide high-quality care while being good fiscal stewards on behalf of the 1.7 million patients whom we care for,” Klibanski said. “While what we are experiencing today is unprecedented, it’s important to remember that we have overcome challenges before during our long history. The stress placed on our workforce and our system over the past several years has been enormous, and the employees at Mass General Brigham continue to show strength and resiliency.”


    MGB is among the nation’s largest nonprofit health systems and is the largest private employer in Massachusetts. Its recent losses are shared by several of its larger peers and come during a year when most of the nation’s hospitals are seeing sustained negative margins.


    Unlike other systems, its commitment to cost reduction isn’t solely based on recent financial performances. Massachusetts regulators ordered MGB to outline a plan to identify and limit spending growth that they said contributed to higher costs for patients across the state. That proposal was submitted in May, rejected and then approved in late September.

  • 23 Nov 2022 11:34 AM | Matt Zavadsky (Administrator)

    The EMS workforce challenges are affecting agencies of every type!

    Saw this column when it first came out in May, and after listening to fire chiefs from all over the country over the past few months explain the challenges they are having with recruiting personnel, especially paramedics, into the fire service, it seems Ben may be really on to something.

    A local fire department in north Texas that provides ambulance service is offering a $10,000 sign on bonus for FF/paramedics.  Other departments in the state are doing similar sign on incentives.

    I was recently told by a well-respected fire chief from an agency that does not do ambulance service that his #1 recruiting advantage over other departments in his area is that his department does not do ambulance service.


    Why so many firefighters don’t become paramedics

    Five factors help explain why our current crop of firefighters and firefighter-EMTs never make the move

    May 28, 2022

    Within fire-based EMS systems everywhere, the numbers of firefighter-paramedics are dwindling. Fire departments are scrambling to fill their immediate vacancies by drawing in new paramedics. Recruitment campaigns promising great benefits, sign-on bonuses and guaranteed shifts away from the ambulance are filling up social media feeds.

    Ten years ago, when fire department jobs were scarce, campaigns like these would have brought in a flood of qualified candidates. Not so in today ’s world. Everyone is hiring. And many agencies that used to require a paramedic license to even be considered have lowered the required qualifications just so they can fill all the empty seats on their fire engines. Even those vacancies have become a struggle to fill.

    It’s time for fire-based EMS to realize that there simply aren’t enough paramedics out there to fix our problem. The answer lies within – encouraging our existing firefighters and firefighter-EMTs to become paramedics. But to do that we must first be honest and talk about the reasons they don’t become paramedics.

    Here is a countdown of the top five reasons firefighters don ’t become paramedics.


    Firefighters and written tests go together like oil and water. We like to get our hands dirty and prove ourselves through action. The thought of going toe to toe with the National Registry is enough to make any firefighter walk away, especially those who struggled through it to become an EMT.


    I’ve heard people say,  “going to paramedic school would be a pay cut.” And they aren ’t lying.

    Firefighter salaries, especially those just starting out, are low. At the beginning of my career as a full-time firefighter-paramedic, I qualified to receive government assistance for free milk, baby formula and peanut butter. I remember losing my temper at a grocery store cashier for trying to shame my wife when she pulled out the big paper tickets that covered the cost of those essential items. I had just come home from a 24-hour shift. I hadn ’t slept. It wasn ’t pretty.

    Eventually, like just about every firefighter I know, I took on a second job. A necessity that many of us depend on just to keep our families afloat. I was lucky enough to have gone to paramedic school before I had kids. Had I waited, I might never have.


    Online learning is not the future of education, it ’s the right now. Associate degrees, bachelor's degrees and even master ’s degrees are being earned at fire station kitchen tables everywhere. And though paramedic programs are adapting to accommodate the modern-day learner, the amount of content, clinicals and rapid-fire pace have held them back from breaking with the classroom.

    Even though paramedic programs are shorter and typically less expensive, the ease with which other college degrees can be earned online is drawing firefighters looking to advance their careers away from earning their gold patch.


    When compared to a suppression apparatus, being assigned to an ambulance means longer hours away from the station and more territory to cover. It brings paperwork, liability and the constant battle to remain professional in the face of disgruntled nurses at overcrowded hospitals. And because firefighter-paramedic numbers are so limited, many are being forced to spend the majority of their careers on ambulances. Due to department necessity, they ’re stuck.

    Firefighters and firefighter-EMTs see what is happening. And many are choosing to ride backward rather than risk being assigned to an ambulance for the next 20 years.


    “I ’m not going to medic school because I want to be a firefighter.”

    To the outside world, we ’re all firefighters. But for those working within fire-based EMS, we are either firefighters or paramedics. The divide is real. So when firefighters and firefighter-EMTs talk about going to paramedic school, they ’re treated as if they are changing teams. They ’re shamed, ridiculed and reminded of all the hardship they will be bringing upon themselves.

    Unfortunately, some are even coached by senior leadership to avoid becoming paramedics so as not to stagnate their careers by being stuck in an ambulance. Of all the reasons firefighters are choosing not to become paramedics, this is the most toxic. Placing individual ambitions above the needs of our respective communities will certainly lead to the failure of our mission.


    For all the problems I listed above, there are solutions – some less complicated than others, but none can happen overnight. It starts at the top with those responsible for cultivating a culture of success. Fire chiefs, if you’re wondering why your fire department isn’t growing its own paramedics, the problem isn’t with the seeds; it's in the soil.

    Go to your city councils, your fire boards, your citizens. Help them understand what firefighter-paramedics do and what it will mean if we run out. Garner their support to create an environment where firefighters who are willing to go through the struggle of achieving the gold standard of prehospital care are valued. Fight for your firefighter-paramedics as hard as you fight for that new fire engine. Show them you care. Because if you don’t, why should anyone else? 

    About the author

    Ben Thompson is a captain in Birmingham, Alabama. In 2016, Thompson developed his department’s first mobile integrated health (MIH) program and shared his experiences from building the program at TEDxBirmingham. Thompson was the recipient of the 2016 Emergency Medical Service Provider of the Year Award and the 2018 Joe E. Acker Award for Innovation in Emergency Medical Services, both in Jefferson County, Alabama. He has a bachelor's degree from Athens State University in Alabama and is a licensed paramedic.

  • 16 Nov 2022 6:44 AM | Matt Zavadsky (Administrator)

    This could be another value-added reason for EMS agencies to partner with hospitals to create Mobile Integrated Healthcare (MIH) ‘safe landing’ programs for patients who might be able to be discharged, either from the ED, or from an IP stay, if community paramedics were able to make scheduled visits, and be available 24/7 for any patient needs.


    Hospitals seek more aid to house patients they can't discharge

    Arielle Dreher

    November 16, 2022

    Health worker shortages are keeping hospitals from discharging patients for post-acute care and prompting pleas to Congress for per diem Medicare payments to cover the longer stays.

    Why it matters: The requests add to a long list of health industry asks that Congress will have to sort through in the lame-duck session and underscore how the fallout from the pandemic is still rippling through the health care system.

    How it works: Discharging patients to long-term care facilities was challenging even before the pandemic, but COVID-19 dramatically disrupted the process, making it hard for facilities to accept patients in the midst of outbreaks.

    It's costly to keep patients in a hospital when they no longer need to be there, since facilities are typically paid a fixed rate based on a patient's condition or diagnosis.

    The patients who can't be discharged are still too sick to go home and may have mobility issues, conditions like diabetes, or mental health needs.

    Providence Health in Spokane, Wash., for example, is on track to spend nearly $18 million this year on nursing care for patients who no longer need to be hospitalized at its two facilities. A handful of patients have been on the premises for more than 100 days, Susan Stacey, Providence chief executive for inland northwest Washington state, told Axios.

    "We're having workforce issues downstream, so that per diem could provide some targeted temporary relief to hospitals," said Aimee Kuhlman, a vice president of advocacy at the American Hospital Association.

    Zoom in: Long-term care facilities continue to grapple with staffing problems, which limits the available spots for a hospital to discharge to.

    The backlog has left patients with medical emergencies waiting on beds and sometimes dying, the American College of Emergency Physicians wrote in a letter to President Biden this month.

    Some emergency departments that board patients have had backups extending into hallways, waiting rooms, and ambulances waiting to offload patients.

    Normally, an emergency department can handle a challenge of tight capacity, high acuity or a staffing shortage, but when all three come together at once, it can quickly overwhelm an ER.

    "The system is at a breaking point," Christopher Kang, president of the American College of Emergency Physicians, told Axios. His group has asked the administration to establish a nationwide council to address capacity problems and other stresses throughout the health system.

    Yes, but: The requests could be drowned out by myriad other health interests seeking their own relief by year's end.

    Nursing homes, long-term care and home health providers each cite a severe shortage of workers as threatening their business models.

    What we're watching: The siloed health care system has many potential gaps in care, and while the pandemic forced closer collaborations, alliances may be difficult to formalize.

    Facilities that accept Medicaid patients could limit the number of spots for those patients, due to payment rates that are lower than private coverage.

    Skilled nursing facilities are still rejecting patient referrals from hospitals at higher rates than before the pandemic, data from WellSky shows.

    The rejection of hospital referrals also could be a sign some facilities are trying to stay above water and maintain higher standards of care.

    "You shouldn't bring a person in you can't care for because it would cause harm to that individual," said Lori Smetanka, executive director of the advocacy group Consumer Voice.

  • 16 Nov 2022 6:40 AM | Matt Zavadsky (Administrator)

    GREAT news for Maine’s EMS providers!  Almost every finding of this Commission could easily be applied to virtually very EMS agency in the country.

    The legislation that set up this commission, AND requires Medicaid pay parity with Medicare, is attached – Replicate in your state?


    Commission recommends annual infusion of $76 million to help Maine’s beleaguered emergency medical services

    A 17-member commission recommended that $25 million immediately go to agencies in danger of failing or leaving the communities they serve.

    November 15, 2022


    AUGUSTA — A blue ribbon commission tasked with studying emergency medical services in the state has suggested an infusion of nearly $80 million a year to keep services afloat.

    At a meeting Monday, members of the commission voted unanimously to recommend that the state of Maine provide at least $70 million a year for five years for the EMS system to support all transporting agencies and $6 million for all non-transporting agencies.

    Maine’s emergency medical services have been in a state of crisis for years, with agencies plagued by steadily declining staffing levels over the past decade, poor Medicare and Medicaid reimbursement rates and high operating costs. Like many other aspects of Maine’s health care system, the pandemic only made the situation worse.

    Democratic Rep. Rachel Talbot Ross of Portland introduced a bill in January that classified EMS agencies as essential services and established the commission, which began meeting in September. Talbot Ross and Sen. Chip Curry, D-Waldo, are co-chairs of the 17-member commission.

    The members voted unanimously to approve the recommendation, save for the two state employees on the panel — Maine EMS director Sam Hurley and Maine Department of Health and Human Services senior advisor Dr. Lisa Letourneau — who abstained from all votes.

    Members also voted unanimously to recommend that $25 million of the $70 million for transporting agencies go to agencies that are in immediate danger of failing or leaving one or more of the communities that they serve.

    This funding would help services across the state “begin to adequately reimburse and provide benefits for our providers in the state of Maine and develop recruitment and retention projects,” Rick Petrie, a paramedic and executive director of Atlantic Partners EMS, said.

    Petrie represents private, for-profit ambulance services on the commission, which also includes state legislators and representatives of the various EMS agencies and health care systems from across the state.

    There are 272 EMS agencies in Maine, according to the latest data provided by Maine EMS, the state licensing and regulation agency that oversees emergency medical services. The multiple types of agencies, or service providers, including private non- and for-profit, hospital-based, community-based nonprofit, and non-fire department-based municipal agencies. There are also three collegiate and two tribal EMS agencies in the state. Most EMS agencies in the state — about two-thirds — are housed within fire departments.

    More than half of all EMS agencies in Maine are transporting services, meaning that they transport patients from a scene to a hospital or other location, and between hospitals. There are just over 100 non-transporting services, meaning they provide treatment at a scene but do not transport patients.

    The commission came up with the $70 million figure using a formula that took into account the cost of service, typical call volume and types of calls.

    “Every service I know of is operating at a loss this year,” said Joe Kellner, the vice president of finance and business operations for Northern Light Health’s home care and hospice division and the chief financial officer for LifeFlight of Maine. Kellner, who represented a statewide association of hospitals on the commission, developed the formula.

    “We know it’s at least $70 million,” he said. “It’s likely quite a bit higher than that because it’s based on efficient service, which is 1,800 calls a year.”

    According to Maine EMS, the majority of EMS agencies answer fewer than 500 calls annually. About a third answer between zero and 99 calls a year.

    “If anything, that number is low,” Kellner said.

    The recommendation language would specify that this funding would be in addition to funding that agencies already receive, such as municipal funding or other subsidies, the members voted. They also stipulated that the state should come up with the funding, not the federal government, which they said would take too long.

    In addition to funding, the commission voted to recommend a permanent commission independent of the Maine EMS Board that could submit legislation.

    The commission will submit its recommendations in a report to the Legislature’s Criminal Justice and Public Safety committee no later than Dec. 7. The commission’s sixth and final meeting will be on Dec. 5. Members will review and approve the report drafted by staff from the nonpartisan Office of Policy and Legal Analysis.

    More information can be found on the commission’s website at

  • 7 Nov 2022 7:39 AM | Matt Zavadsky (Administrator)


    Tip of the hat to Kolby Miller, CEO of Medstar in Michigan for finding this report!

    Outstanding research on the demands being placed on the U.K. NHS Ambulance Trusts.  Lots to unpack in this report, and strongly encourage everyone to take 10 minutes to review it.

    Keep in mind, health, and healthcare outcomes for virtually all types of medical care in the U.K. is substantially better than in the U.S., with 1/3 the expenditure, according to data from the Organisation for Economic Co-Operation and Development.

    Among the most interesting findings –

    • Of the 10.9 million ‘999’ calls for EMS, only 7.9 million (72.5%) received a response for a face-to-face assessment. 
      • NHS employs extensive use of nurse and other provider telephone assistance in their ‘999’ centers to reduce the need to send a resource into the field.
      • Hear and treat or hear and refer programs help reduce actual responses for face-to-face assessments!

    Note the response priorities and time goals. 

    We have A LOT of work to do….


    Why have ambulance waiting times been getting worse?

    4 November 2022


    Ambulance services in England are under immense pressure. In July 2022, all ambulance services in England declared REAP (Resource Escalation Action Plan) level four, reflecting potential service failure. Volumes of calls to 999 are increasing, patients in distress and pain are waiting longer for help to reach them, and ambulance teams feel unable to do their job well.

    The new Secretary of State for Health and Social Care has previously named cutting ambulance waits as his number one priority. As he takes up the role for the second time, he will again need to include ambulances in his list of priorities for the health and care system. Steps taken to date to help address the underlying issues have not yet had an impact on the pressures facing ambulance services.

    This analysis looks at ambulance service performance and explores the contributing factors and priorities for improvement.

    Patients are waiting longer to be treated

    10.6 million calls were answered by the ambulance services in England between April 2021 and March 2022. Around 7.9 million of these required a face-to-face response. This is around one per year for every seven people in England. A city of 500,000 people (around the size of Sheffield) would have around 200 ambulance service call outs per day.

    Ambulance response time targets differ depending how critical the incident is. Table 1 shows the four categories, their targets and response times for 2018/19 and 2021/22. There are targets for the average response time (the average time for all incidents to be responded to) and the 90th centile (the time within which 90% of incidents should be responded to). To ensure that the patient receives attention as quickly as necessary, the ambulance service may respond to incidents with traditional ambulances and other modes of transport including air ambulance and motorbike.

    Response times are increasing across all categories and are now well above target, though less so for the more serious categories, in both absolute and relative terms. This is because when services are under pressure serious incidents are given priority by ambulance services. Figure 1 shows increasing response times across all regions.

    Long ambulance waits put further pressure on the system. For example, those waiting for an ambulance may call the emergency services to find out where the ambulance is, placing further demand on operators to answer more calls. The average call answer times increased from 7 seconds in 2018/19 to 32 seconds in 2021/22. In the same time periods, the number of answered calls increased from 8.74 million to 10.59 million.

    Demand and capacity in the ambulance service

    Figure 2 shows a simplified pathway for a patient needing urgent assessment or treatment at the hospital; for instance, a category 1 incident where an ambulance is needed.

    The response time (typically from when the call is answered to when the ambulance team arrives at the patient’s location) depends on both the demand for ambulances and the capacity of the ambulance service. If demand increases (for example, there are more incidents requiring an ambulance), or capacity reduces (for example, because there is a shortage of crews) the average wait for an ambulance will be longer.

    Demand for ambulances

    Demand depends on both the number of calls received that require a face-to-face response (including sending an ambulance), and how each incident is categorised (for example, multiple resources may be sent to a life-threatening incident).

    Figure 3 shows incidents that the ambulance service attended from April 2018 to September 2022 overall and by category. It indicates that the total volume of incidents is similar to the volume seen in April 2018, but the composition of incident types has changed. There has been an increase in incidents being resolved over the phone (‘hear and treat’) but most incidents still require a face-to-face response. In 2021/22 a higher proportion of incidents were life-threatening (category 1, 12%) or emergency (category 2, 66%) compared with 2018/19 (9% and 60%, respectively). These life-threatening and emergency incidents require more resources than categories 3 and 4. The shift towards these more urgent incidents has increased the demand for ambulance services.

    Ambulance service capacity

    The capacity of an ambulance service can be considered the maximum rate at which it can deal with incidents. This depends on the number of ambulances there are in the system and the length of time each ambulance spends dealing with an incident. As depicted in Figure 2, this is the time taken from dispatch to an ambulance being ready for the next call.


    Between March 2019 and March 2021 the number of full-time equivalent paramedics increased by around 13%, but there has been virtually no increase over the past year. However, as Figure 4 shows, sickness absence in the ambulance sector increased from 5% in March 2019 to 9% in March 2022 – which implies a reduction in capacity of around 4% points. This is higher than the increase seen at other organisation types. The most common reason for sickness absence among ambulance staff is poor mental health, responsible for a fifth of all sickness absence in March 2022.

    Despite increases in the workforce, in the 2021 NHS Staff Survey, only 20% of ambulance staff said there were enough staff in their organisation for them to do their job properly, compared with 30% in the 2019 survey.

    Ambulance cycles and handover times

    Capacity also depends on how long it takes ambulances to complete calls. For example, a 10-ambulance fleet in which each ambulance is able to complete a call in an hour will have a capacity of 10 calls per hour (or one call every 6 minutes). If the length of time it takes to complete a cycle goes up by 15 minutes – for example because the ambulance must spend an extra 15 minutes waiting at the hospital to hand over the patient – the capacity of the service will reduce from 10 calls an hour to eight.

    Handover time greatly affects ambulance capacity. This is the time from arrival at the A&E department to handing the patient over to the care of A&E staff and should take less than 15 minutes. 50% of ambulance patients are conveyed to A&E (others are treated on the scene or taken elsewhere).

    Figure 5 shows that the percentage of handover times exceeding 30 minutes was higher in winter 2021–22 than in previous winters. Longer handover times mean that patients are not receiving the care that they need from the hospital. The Association for Ambulance Chief Executives (AACE) suggests that in July 2022 alone, 40,000 patients may have suffered potential harm as a result of waiting more than an hour to be handed over to the hospital. Handover delays also mean that ambulance teams spend vital time queueing outside hospitals rather than responding to other calls in a timely way. AACE estimates that in July 2022 the total time lost to handover delays exceeding the 15-minute standard was equivalent to 4,000 ambulance job cycles. We estimate that this amounted to almost 20% of total ambulance capacity in July. Handover delays exceeding an hour have also been worsening. According to 2019 national ambulance data that we requested from AACE, more than 1 in 10 ambulances waited over an hour in July 2022 – up from almost 1 in 50 in 2019.

    Impacts on ambulance waiting times

    Since 2018/19 demand for ambulances has grown as a result of shifts in the acuteness of cases and although the workforce has increased, this had been moderated by higher levels of sickness absence. However, the biggest change has been the sharp increase in A&E handover times, putting further pressure on ambulance capacity.

    But can these changes in handover times lead to the sort of increases in average waiting times that we’ve seen – from around 33 minutes in 2018/19 (across all categories) to nearly an hour in 2021/22? Box 1 shows this can be the case. In our simple model, a 15-minute increase in average handover time increased average dispatch time from 4 minutes to 36 minutes. This illustrates the more general point that in complex systems being run close to capacity, relatively small changes in one area can have disproportionate effects in another. Conversely, resolving the drivers of increased handover times would release ambulance capacity and could help reverse the large increases in waiting times.

    Three ways to help improve ambulance service performance

    Based on our analysis of the causes of increased ambulance waiting times, we consider three ways of improving performance.

    1. Reduce handover delays by improving patient flow

    The increase in handover delays is a major contributor to the decline in ambulance service performance, so action to reduce these delays is a priority.

    When an ambulance arrives at A&E, the patient will either be admitted to hospital, transferred or treated and discharged. Waits have been increasing for all patients attending A&E, with patients admitted to hospital in an emergency now more likely to be waiting more than 4 hours (from when the decision to admit them was made) than patients admitted before the pandemic (Figure 7).

    Evidence suggests that the increases in delays for admission are the result of reduced numbers of unoccupied beds – a 1% point increase in bed occupancy decreases the probability of meeting the 4-hour wait target for A&E by 9.5% points. Occupancy levels in hospitals have remained relatively stable since 2018/19 but since February 2022 this has been above 92.5%, resulting in fewer unoccupied beds (Figure 8).

    One reason for high bed occupancy is low and declining numbers of beds relative to demand. England has a low number of hospital beds per capita and in recent years bed numbers have fallen as admissions have risen. Increasing the number of beds, as NHS England is planning, will help but is only part of the solution.

    Bed occupancy can also be reduced by discharging patients from hospital who are medically safe for discharge – the number of which is increasing. Delayed discharges can result from waits for assessments or decisions by allied health professionals and clinicians, waits for non-acute NHS care and waits for social care assessments, placements and funding for domiciliary and residential social care. Waits for social care are the result of chronic workforce shortages, a fragile provider market, and insufficient levels of government funding. In September, the government announced a £500m fund to support discharge from hospital into the community, but this is to be funded from existing DHSC and NHS England budgets. A longer term approach to funding and staffing social care is needed to relieve pressure on hospitals and to better support those needing care.

    2. Expand and support the ambulance workforce

    A fully staffed and healthy ambulance workforce, better supported to do their jobs, is vital. The number of vacancies has almost doubled in the past year and sickness absence rates have increased significantly. The most recent annual NHS staff survey found that 43% of ambulance staff are thinking of leaving their organisation, and only 26% said they are satisfied with their level of pay (down from 29% in 2019).

    Ambulance staff were also most likely to report feeling burnt out (51%), followed by nurses and midwives (41%). 61% of ambulance operational staff report feeling unwell as a result of work-related stress and 46% had experienced harassment, bullying or abuse from patients and/or the public. In response to growing concern regarding the mental health of ambulance staff, guidance and tools have been published by AACE and others on preventing suicide in the ambulance service.

    Increasing sickness absence rates in the acute sector and others (Figure 4) reduce capacity and may have knock-on effects on waiting times for acute admissions, and ambulances. This is neither safe, nor sustainable. Action is needed to ensure retention of valuable staff, recruit new talent and secure a resilient health and care workforce.

    NHS England has also sought other ways to expand ambulance capacity. In August a deal was struck for St John’s Ambulance to provide auxiliary services to the NHS. This contract will see more than 5,000 hours per month of support provided, but this pales in comparison to the scale of the problem. In July alone 152,000 hours (the equivalent to 4,000 job cycles per day) were lost to ambulance handover delays in excess of 15 minutes.

    3. Reduce demand for ambulances through improving access to other services

    Patients who cannot access the care they need may instead turn to the ambulance service or A&E. One example is children and young people experiencing mental health problems, the number of which is growing. Mental health services are not expanding in line with rising needs, leaving many with limited or no support and increasing use of crisis care. The majority of mental health-related ambulance callouts to children and young people in Wales were subsequently transferred to A&E.

    Some trusts have set up ‘emergency mental health departments’ to create a more suitable alternative for people in crisis and relieve pressures on A&Es. The government announced £7m for specialised mental health ambulances across the country to reduce the use of general ambulance callouts for those experiencing crisis. Improved data quality, better linkage of datasets across services and more regular collection of prevalence data would inform service expansion and target support at those in need.


    Ambulance services in England were under immense strain during the summer months. Pressures here and across the health and social care system are only likely to increase as we approach winter, and there is an urgent need to address the factors contributing to this strain. Solutions to relieve pressure on the ambulance service and improve outcomes are being developed by local trusts, national charities and by the government. However, underlying this complex problem are issues of funding, workforce and service models. Until there is acknowledgment of this much broader context of pressures, attempts at a solution will only address small elements of the problem.

    National, long-term strategies are required to address the crisis in social care that prevents effective patient flow through hospital and causes queues of ambulances outside hospital doors. There must be clear steps put in place to ensure that the workforce shortages that reduce capacity and worsen burn out are resolved. Finally, long-term strategies are also needed to ensure that services including mental health, dentistry and general practice are well-funded and accessible to the patients who need them. Much as seemingly small changes have had huge, injurious consequences for ambulance performance and patient outcomes, solutions targeted at addressing the root causes can help restore performance.

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