News & Updates

This news report highlights the interest of health systems and payers using Community Health Workers (CHW) to help reduce preventable ED visits.

Local EMS agencies are trusted community partners, and this may be an opportunity for agencies to:

• Potentially include CHWs as part of their MIH/CP programs
• Cross-certify their Community EMTs and Paramedics as CHWs (MedStar in Fort Worth started doing this years ago, working with the state to allow CHW certification based on MIH training programs and field experience, without the need to attend classes for the certification).
• Educate health systems and payers that Community Paramedics can fill many of the same valuable functions as CHWs.

Here's a 2017 article in EMS World that explains the potential benefit of CHW certification for Community EMTs and Paramedics: 
https://www.hmpgloballearningnetwork.com/site/emsworld/article/12288433/is-chw-certification-the-magic-bullet-for-community-paramedics

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Looming uninsured surge may overwhelm ERs. Here’s who can help.

By: Alex Kacik

August 18, 2025

https://www.modernhealthcare.com/providers/mh-medicaid-cuts-er-overcrowdfng-kaiser-permanente

Health systems are deploying an often-overlooked resource to combat a potential increase in uninsured patients — community health workers.

Health systems hope community health workers can help prevent people from losing insurance coverage due to expiring subsidies for health insurance exchange customers and the new tax law.

Providers warn a rush of uninsured people could overwhelm already overcrowded emergency departments and hospitals.

Even if uninsured rates increase, employees who are embedded in the community can help keep people connected to the healthcare system and reduce unnecessary emergency department visits, executives said.

“There are tons of opportunities to better integrate community health workers across the healthcare system,” said Dr. Bechara Choucair, chief health officer at Kaiser Permanente. “Community health workers play a significant role in helping people access services and coverage.”

Providers are bracing for a potential influx of uninsured patients, who tend to defer care and use the emergency department more frequently than those with coverage. The “Big Beautiful Bill” is expected to result in 11.8 million Americans losing insurance by 2034, according to projections from the Congressional Budget Office. The tax law is poised to cull Medicaid enrollment in early 2027 through work requirements and rigorous eligibility redeterminations.

Millions more may lose their insurance if Congress does not extend enhanced subsidies that help curb premiums for Affordable Care Act exchange customers. Hospitals across the country are working with policymakers to get them to extend those subsidies and limit coverage lapses.

Many systems are already managing rising emergency department utilization and sicker patients, creating care backlogs, driving up costs and limiting access. A spike in patients without insurance would accelerate those trends, experts said.

It’s a snowball effect, said Anna Adams, chief government relations officer at the Georgia Hospital Association.

“When patients don’t have coverage at all and can’t get annual wellness checkups or see specialists, they go into the emergency department with significant problems because it is the only option,” she said. “The emergency department is not only an inappropriate care setting, but it creates a volume issue where emergency departments are full and they have to divert patients.”

Health systems, including Kaiser, are leaning on community health workers to keep low-acuity patients out of the emergency department, boost preventative care and maintain insurance coverage, Choucair said.

The Oakland, California-based integrated health system launched a pilot program in the Pacific Northwest about five years ago that placed community health workers in care teams that identified patients who were likely to end up in the emergency room or hospital. Community health workers used the question, “What do you need to improve your health?” to guide a treatment plan where those employees offered coaching, social support, advocacy and guidance.

The program, which Kaiser is expanding across the Pacific Northwest, the mid-Atlantic region and potentially other markets, has led to an annual reduction of roughly two fewer days in the hospital per patient and $82 in monthly savings per member, Choucair said. The return on investment for community health workers is more than 2-to-1, he said.

Community health workers could play an even bigger role in preventing lapses in coverage by helping people with paperwork, collecting patient data and connecting them with job opportunities and other community resources, Choucair said.

“There is no doubt that this type of model can be helpful for people navigating eligibility requirements and access to services and benefits,” he said. “Community health workers could add a ton of value here.”

Community health workers typically focus on preventative care. They can help people navigate coverage and teach residents in low-income areas about prenatal care, screenings, healthy eating habits and community-based resources.

But health systems have been relatively slow to focus on such strategies, despite executives who often say their organizations are bridging gaps in transportation, housing, nutrition, employment and other social determinants of health. Services that community health workers provide may not be covered by insurance, which is in part why hiring has lagged.

But hospitals are planning to recruit more community health workers, executives said.

“We are interested in working with community organizations to identify individuals at risk of losing coverage because of work requirements and preemptively help someone qualify for an exemption or connect them to an employment opportunity,” said Mark Schaefer, vice president of system innovation and financing at the Connecticut Hospital Association.

Insurers have also increasingly pushed early treatment interventions through alternative payment models, incentivizing the hiring of community health workers.

Alternative payment models that reward providers for decreasing costs, reducing hospitalizations and improving outcomes have fueled Endeavor Health’s team-based care models, said Dr. Sanjeeb Khatua, chief physician executive at Endeavor.

The Chicago-area health system plans to expand and better integrate its care teams, consisting of pharmacists, social workers, community health workers, care coordinators, advanced practice practitioners, primary care physicians and specialists, across its network, he said.

“We’re learning how to intervene with patients from a social perspective in a different way, which traditionally health systems haven’t been great at,” Khatua said. “What’s happening [on a federal level] is going to make us move quicker on partnerships to help us with that.”

These types of care models will not only help patients maintain insurance coverage by identifying at-risk patients, but they will also help direct people without insurance away from the emergency department to the right location, he said.

“Our duty is to make sure people have the coverage they are supposed to get,” Khatua said. “Most health systems are going to have to augment team-based care with technology that allows us to identify these patients further upstream and build the care models that are going to be needed to alleviate the pressures to come."

As state legislatures promulgate laws designed to protect patients from ground ambulance balance bills due to surprise underpayments by insurers, insurer's often cite potential increases in commercial insurance premiums as a reason to oppose patient protection legislation.

The state of New Hampshire recently enacted such legislation, effective January 2026. The Fiscal Note created as part of the legislative process may shed light into the minimal impact these laws have on commercial insurance premiums.

This information could be useful as additional states consider legislation to protect patients from ground ambulance balance billing due to insurance underpayments.

For more information on patient protection laws, visit the following links:
Report from the Advisory Committee on Ground Ambulance and Patient Billing (GAPB) 
National Conference of State Legislatures EMS Legislation Database
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New Hampshire SB 245 contains many of the typical provisions for patient protection from balance billing by ground ambulance services; State regulated insurers (with the notable exception of Medicaid MCOs) must directly pay either the fees established/approved by localities, or, in the absence of locally approved fees, 325% of local Medicare Allowable.
 
However, of most interest is the fiscal note attached to the Bill, which contains the following language:
 
“This bill mandates that managed care health insurance plans cover emergency ground ambulance services, requiring health carriers to pay nonparticipating ambulance providers either the rate set by local governments or 325% of the Medicare rate.  Additionally, it caps cost-sharing for these services at $100, revises prompt pay requirements, and mandates that carriers specify whether the plan is "ERISA" or "Non-ERISA."
 
"The Insurance Department states the bill's provisions are expected to increase health insurance premiums as carriers adjust to higher reimbursement rates for ambulance services.  The 325% Medicare rate cap is a significant increase from current reimbursement levels, which will likely result in higher premiums in subsequent years. The $100 cap on cost-sharing may also contribute to higher premiums or increased cost-sharing for other services.  While the exact fiscal impact is indeterminable, any significant premium increases would likely lead to higher insurance premium tax revenue."
 
"Local and county governments purchasing health insurance may face higher premiums. Additionally, localities and counties providing ambulance services will be affected by the higher reimbursement rates for these services, though the impact will vary by locality."

"Using similar cost estimate methodologies as a consultant firm the Department hired to assist with a financial impact estimate on Commercial Market Premiums, the Department estimates this bill could increase commercial market premiums by $1.13-$1.38 per member per month (PMPM), translating to an approximate 0.5% increase in premiums, or $15 million in aggregate. This estimate is based on 325% of Medicare rates and may be higher if local governments set rates above 325%."
 
This essentially means that premiums are estimated to increase an average of $1.26 per member, per month, or $15.12 per YEAR, or $60.48 for a family of 4.

This study from Florida Atlantic University may provide an opportunity for innovative EMS agencies and their Medical Directors to work with local Skilled Nursing Facilities, as well as other healthcare facilities, on processes designed to reduce preventable ED visits.

Value demonstration to payers for reduced expenditures resulting from ED visit reduction could be a funding source to create financial sustainability for the program.

Tip of the hat to Greg Friese of EMS1 for sharing this report!
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Most Hospital Visits of Vulnerable Nursing Home Residents Avoidable

By gisele galoustian 

7/24/2025

https://www.fau.edu/newsdesk/articles/hospital-transfers-nursing-home-residents.php

In one of the largest studies of its kind, researchers found that up to 80% of emergency department visits and more than one-third of hospitalizations in severely impaired and terminally ill nursing home residents were potentially avoidable.

Hospitalizations and emergency department (ED) visits can be distressing and costly for nursing home residents – especially those who are severely impaired or terminally ill. Despite their vulnerability, these individuals are frequently transferred to hospitals, even though up to 40% of such transfers over the past 25 years are considered potentially avoidable by health care professionals.

These unnecessary transfers not only cause distress and discomfort for residents and families but also lead to hospital-acquired complications and added costs for the health care system. In the United States, hospital transfers from nursing homes significantly contribute to health care costs, particularly for Medicare, with an estimated $14.3 billion annually. 

Most studies of hospitalizations and ED visits among severely impaired and terminally ill nursing home residents have not examined diagnoses associated with hospitalizations and potentially avoidable hospitalizations in any detail, nor have they separated severely impaired from terminally ill residents.

In one of the largest studies of its kind, researchers from Florida Atlantic University’s Schmidt College of Medicine and Christine E. Lynn College of Nursing, and collaborators, conducted a secondary analysis of data from 264 nursing homes across the U.S. to dive deeper into this issue.

Using information from a randomized trial of the Interventions to Reduce Acute Care Transfers (INTERACT) program, the study identifies the specific medical conditions most frequently linked to hospitalizations, ED visits and those considered potentially avoidable among severely impaired and terminally ill nursing home residents.

Results of the study, published in the Journal of the American Medical Directors Association, reveal that among more than 6,000 severely impaired nursing home residents, one in three experienced a hospitalization – more than one third of which were potentially avoidable. Nearly 20% visited the ED without being admitted, and 70% of those visits were deemed preventable.

Among more than 5,800 terminally ill residents, hospitalizations and ED visits were less common but even more likely to be unnecessary. Notably, 80% of ED visits in this group could potentially have been avoided.

In the severely impaired group, feeding tube complications were the most common reason for these visits, often due to blockages, dislodgement or infections. Transfers related to trauma – largely from falls, including head trauma and fractures – were common among terminally ill residents. And in many cases, deemed preventable. 

The study also revealed that certain diagnoses were frequently associated with potentially avoidable hospitalizations. Among severely impaired residents, urinary tract infections (UTIs), seizures, and low blood pressure (hypotension) were the most common causes of hospital stays that could have been prevented with timely and appropriate care. UTIs, in particular, are widely known to be over-diagnosed and over-treated in nursing home settings, despite clear clinical guidelines recommending treatment only when specific findings are present.

For terminally ill residents, pneumonia, UTIs, acute kidney failure, and heart failure were most often linked to avoidable hospitalizations. Other common diagnoses across both groups included infections, breathing difficulties, and altered mental status.

“The specific diagnoses we identified such as UTIs, pneumonia, and sepsis aren’t surprising, but they highlight some clear, actionable opportunities to improve care,” said Joseph G. Ouslander, M.D., senior author and professor of geriatric medicine, Schmidt College of Medicine. “These are conditions we know how to manage better in nursing homes, using existing guidelines, care paths and preventive strategies. With the right tools and staffing, many of these hospital transfers could be avoided, reducing both resident suffering and unnecessary health care costs.”

While the definition of “potentially avoidable” varies, the findings align with previous studies and underscore the urgent need for proactive care strategies. Many of these hospitalizations could be prevented through clearer care protocols, timely symptom management, and, critically, regular advance care planning.

The researchers say ensuring that residents have documented care preferences and that families understand their options can help avoid crisis-driven decisions and reduce needless transfers. However, barriers such as reluctance to enroll in hospice and financial constraints still pose challenges. Addressing these issues could improve quality of life for residents and free up hundreds of millions in health care spending for reinvestment in other aspects of care.

“To reduce potentially avoidable hospital transfers, we need to strengthen the capabilities of nursing home staff and ensure active involvement from skilled medical directors and clinicians,” said Ouslander. “This isn’t just about individual effort – it requires support from nursing homes, provider organizations and policymakers.

We need bold changes, like pragmatic national staffing standards, better-resourced facilities for complex care, and payment models that truly support high-quality, person-centered care for the most vulnerable residents.”

Study co-authors are Gabriella Engstrom, Ph.D., corresponding author and a research assistant professor of emergency medicine, FAU Schmidt College of Medicine; Zhiyou Yang, a data analyst at Massachusetts General Hospital; Bernardo Reyes, M.D., program director, internal medicine, HCA Florida Aventura Hospital; Ruth Tappen, Ed.D., professor and Christine E. Lynn Eminent Scholar, FAU Christine E. Lynn College of Nursing; and Peter J. Huckfeldt, Ph.D., Vernon E. Weckwerth Professor in Healthcare Administration Leadership, Division of Health Policy & Management, University of Minnesota. 

This work was supported by the National Institutes of Health/National Institute for Q5 Nursing Research. 

The study analyzed data from the federally mandated Minimum Data Set (MDS 3.0), which includes assessments of nearly all residents in Medicare- or Medicaid-certified U.S. nursing homes. Researchers focused on a specific subset of nursing home residents with defined clinical and functional impairments, allowing for a more detailed examination of outcomes in this high-risk group. While the findings offer important insights into this vulnerable population, they are most applicable to residents with similar characteristics.

With shifting legislation and rising costs, EMS leaders must master the art of financial transparency. 
 
This article in EMS1 explores the financial dynamics of ambulance services, including revenue models, cost structures, and tips to effectively communicate the economic challenges we face in a dynamically changing healthcare and regulatory landscape.

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The true cost of a 911 call: Breaking down EMS economics
This guide demystifies ambulance funding models, cost drivers and how to make the numbers make sense.
July 22, 2025
Matt Zavadsky, MS-HSA, EMT
 
https://www.ems1.com/ems-management/the-true-cost-of-a-911-call-breaking-down-ems-economics

As EMS systems and ambulance agencies enter one of the most tumultuous times in our young industry, it is crucial that we articulate the economics of EMS delivery in a transparent and consistent manner, using proper terminology.

 
Current events that will likely alter the EMS economic model include:

• Patient protection/balance billing legislation
• Medicare cost reporting
• Essential service designation
• Federal legislation that has the potential to dramatically change Medicare and Medicaid reimbursement and Ground Emergency Medical Transport (GEMT) programs

Ambulance service is a critical link in the healthcare chain, not only representing the first point of contact for patients in emergencies, but also moving patients throughout the healthcare system. Behind the medical care delivered by EMS personnel lies a complex financial ecosystem that keeps these lifesaving resources serving local communities and health systems.
 
This article explores the financial dynamics of ambulance services, including revenue models, cost structures, and tips to effectively communicate the economic challenges we face in a dynamically changing healthcare and regulatory landscape.

Direct costs and cost drivers
There are three primary drivers of direct costs in ambulance service delivery:

Response time. Shorter response time goals mean more available ambulances will be needed to meet that goal. Longer response time goals mean less ambulances are needed. This is the definition of the “cost of readiness.” According to the recent Medicare Ground Ambulance Data Collection System (GADCS) report, labor (including wages and benefits) represents 69% of the cost of ambulance service delivery, so it makes sense that the more resources deployed in the system, the higher the cost.

Staffing level. Advanced Life Support (ALS) ambulances cost more to operate than Basic Life Support (BLS) ambulances due to wages, equipment and medication expenses. Wage expenses are compounded by overtime and pay incentives that may be necessary to meet staffing goals for ALS units.

Resource deployment model. EMS responses generally increase during the day and decrease overnight. Static or fixed deployment models, where the same number of ambulances are staffed 24/7, lead to either a potential shortage of ambulances during peak demand times, or an overabundance of resources during lower response volume periods. Staffing the number of 24/7 units based on peak demand times leads to underutilized resources and higher costs. 

Other direct costs that should be included in the cost-of-service delivery include capital depreciation and operational expenses — medical supplies, fuel, maintenance, repairs and any costs associated with technology (e.g., software, cellular connectivity, etc.).

EMS overhead costs
Overhead costs include costs for dispatch services, medical direction/quality management, administration and facilities. Some of these costs could be shared with other non-ambulance delivery functions and determining the allocation of those costs is important. For example, if an ambulance is housed at a station that also houses fire trucks and police cars, the facility cost for the percentage of the space the ambulance takes up in the station should be counted as a cost for ambulance services.
 
An often-overlooked cost in ambulance service delivery is the cost of uncompensated care. Uncompensated represents the financial burden of providing services without receiving payment, either due to charity care or bad debt. While it’s not a direct expense like employee salaries, it reduces the revenue an ambulance provider can collect, impacting financial stability and ability to provide services.

Explaining EMS costs
Explaining ambulance service delivery costs to laypersons is an art and a science. Stating an annual total expense number may not adequately communicate the cost-of-service delivery. There are several ways you can make costs more understandable:

• Cost per response (responses/total expenses)
• Cost per transport (transports/total expenses)
• Cost per patient contact (patient contacts/total expenses)
• Cost per unit hour (staffed unit hours/total expenses)

It may be beneficial for agencies to start tracking costs and revenue on a per-patient-contact basis, as innovative agencies are engaging in effective treatment in place models that reduce the actual number of transports, making the per-transport metric perhaps less relevant. Each of these metrics, tracked over time, can be very useful in explaining service delivery costs to stakeholders.
 
Revenue streams: Where the money comes from
EMS systems are essentially funded from two buckets: Fee for service (FFS) revenue and tax subsidies. When the cost-of-service delivery, based on desired service level, exceeds the FFS revenue that is generated from those services, public tax subsidies will likely be necessary. As good stewards of public dollars, ambulance service leaders should do all they can to maximize FFS revenue to reduce tax burden on local communities. This includes a fee structure that is realistic for the cost-of-service delivery. For example, if your transport cost is $1,000, billing less than $1,000 for the service not only undervalues your services, but places an undue burden on the taxpayer as a result of lower FFS revenue.
 
Medicare and Medicaid reimbursements for ambulance service are based on a fee schedule (which often reimburse less than the cost of service delivery) and do not currently allow patient balance billing. Therefore, patients covered by these programs are not impacted by your fee structure. Commercial insurers typically reimburse a percentage of what is billed, so billing less than the cost-of-service delivery is in essence using tax dollars to subsidize commercial insurers. Ambulance agencies can minimize fee impacts on patients by implementing billing policies that allow for writing off large bills to patients who lack insurance coverage.

Managing your revenue cycle
Effective ambulance billing is complicated, and heavily dependent on technology and computer interfaces. As such, many ambulance agencies have made the strategic decision to outsource their billing to companies that have the wherewithal to invest in technology and personnel training to help assure ambulance claims are appropriately processed and paid.
 
The companies can also develop statistical analysis and reports that can help monitor the revenue cycle and recommend policies and procedures to maximize FFS reimbursement. It is important to note that outsourcing your billing function does not relieve your responsibility to vigorously monitor the billing agency’s performance and regulatory compliance.
 
Explaining revenue
Just like costs, explaining revenue data can be complex and breaking down revenue to explainable metrics for laypersons is essential. There is often a misunderstanding between total billed charges (gross revenue) and the actual cash received (net revenue). It is important for agencies and their stakeholders to know both data metrics. While both metrics are important, the actual dollars received is more meaningful, as those are the amounts that are used to offset the cost-of-service delivery.
 
The most recent PWW|AG EMS Financial Index Report revealed that while the national average base fee billed charge for an ALS emergency call is $1,330, the actual amount collected is $513. When comparing costs for service delivery to the revenue received, ambulance agencies should be using their amounts collected, not billed charges.
 
Like costs, FFS revenue should be broken down on a per response, per patient contact, and per transport basis to help paint the revenue picture:

• Net revenue per response (responses/total FFS net revenue)
• Net revenue per transport (transports/total FFS net revenue)
• Net revenue per patient contact (patient contacts/total FFS net revenue)
• Net revenue per unit hour (staffed unit hours/total FFS net revenue)

If your agency receives a tax subsidy, you should complete this same analysis for the tax revenue component of your funding.

Putting the EMS economic picture together
Once you’ve collected your costs, fees for service and any subsidy revenue, you can now create simple tables and charts that paint the economic picture of your service delivery model. These metrics should be tracked and reported at lease monthly, to identify any trends or outliers.
 
We are in very turbulent financial times for EMS and ambulance service delivery, and our profession needs to be able to express complex financial data in terms that the public, elected officials and regulators can understand. We also need to be consistent with how we are tracking and reporting these complex analyses.

Elected and appointed officials, and the public, have a limited understanding of what it takes to provide effective EMS and ambulance delivery. Too often, we are perceived as simply a “ride to the hospital,” when the true value of service delivery is getting the right resource to the right patient, at the right time and in the right setting. Using transparent, consistent and digestible tools to educate our stakeholders may help them understand that the ride to the hospital is the least expensive part of what we do.
 
We hope this will assist agencies with developing and reporting their economic situations to effectively guide public policy decisions. If you need any assistance developing financial reports like these for your agency, please feel free to let us know.

Helpful resources:

• Pulse of EMS Finance: Summer Webinar Series
• PWW|AG webinar on Medicare ground ambulance data collection survey report
• Rethinking emergency medical services: Applying evidence and data to redesign response models for a resilient and sustainable future
• NAEMT National Survey on EMS Economics EMS Economic and Operational Models
• PWW EMS Law Ambulance Billing Related Forms
• Revenue Cycle Management 101: A Preliminary Guide to EMS Billing

From shrinking Medicaid rolls to rural hospital closures, the 870-page "One Big Beautiful Bill Act" (OBBBA) could shake EMS to its core.

This article in EMS1.com highlights the 7 key takeaways to help your agency prepare.

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The ‘One Big Beautiful Bill Act’: What EMS leaders must know now

July 22, 2025

Steve Wirth & Matt Zavadsky, MS-HSA, NREMT

PWW Advisory Group (PWW|AG)

https://www.ems1.com/legislation-funding/the-one-big-beautiful-bill-act-what-ems-leaders-must-know-now

The One Big Beautiful Bill Act (OBBBA) has the potential to cause a seismic shift in how prehospital care is funded and delivered. On July 15, the consultants at PWW Advisory Group, in partnership with EMS Management and Consultants (EMS|MC), conducted a national webinar highlighting seven key aspects of the 870-page law that are likely to impact EMS in some way or other.

While the Act’s broader goals are aimed at deficit reduction and structural Medicaid reform, its cascading impact on EMS agencies — particularly those already walking the tightrope of financial sustainability — requires urgent attention and coordinated action by EMS agency leaders and advocacy groups.

Here’s a summary of the bill’s most critical provisions that have the potential to impact EMS agencies and recommended specific, strategic action steps EMS leaders should take to prepare for what could be the most disruptive fiscal environment in EMS history.

1. Medicaid changes: A tectonic shift in payer mix

The OBBBA includes significant changes to Medicaid eligibility and cost-sharing that could drastically reduce Medicaid beneficiaries and increase the uninsured population:

• Work requirements (Dec. 31, 2026)
• Eligibility restrictions for immigrants (Oct. 1, 2026)
• More frequent re-determinations and reduced retroactive coverage (Oct. 1, 2026 and Jan. 1, 2027, respectively)
• Mandatory co-pays for adults Medicaid beneficiaries covered through Medicaid expansion (Oct. 1, 2028)

These provisions are expected to push many current beneficiaries out of Medicaid, likely shifting EMS patient populations from insured to uninsured. With Medicaid already a significant payer for ambulance services in many communities, the result could be substantial revenue reductions.

Action steps:

• Conduct detailed payer mix and economic impact modeling
• Partner with state officials and community organizations to forecast coverage loss
• Improve real-time eligibility verification systems and field documentation
• Advocate for state reimbursement and alternative funding strategies
• Explore evidence-based, patient-centric system delivery changes that reduce costs and increase efficiencies

2. Potential threats to Medicaid supplemental payment programs

Several provisions in the OBBBA could severely restrict the funding mechanisms states use to bolster Medicaid payments to EMS agencies and other healthcare providers:

• Moratorium on new provider taxes (effective immediately)
• Cap on state-directed payments to no more than the Medicare rates (2028)
• Reduction of Safe Harbor Provider Tax threshold from 6% to 3.5% (2028-2032)

Programs that are designed to provide supplemental payments to providers, like Ground Emergency Medical Transportation (GEMT) programs, could see drastic revenue reductions — an especially critical issue for agencies in states where GEMT funding is integral to operational stability. New programs approved locally but not submitted to CMS for approval as of the OBBBA’s effective date will likely not be authorized.

Action steps:

• Evaluate your state’s impact of provider tax reductions
• Educate policymakers on how reduced payments threaten service delivery
• Explore evidence-based, patient-centric system delivery changes that reduce costs and increase efficiencies

3. Commercial insurance market disruption and exchange enrollment limits

Provisions in the OBBBA also aim to scale back Affordable Care Act (ACA) Exchange enrollment through shorter windows for enrollment, eliminating auto-enrollment features and reductions in premium subsidies. This could result in many patients currently covered by commercial insurance through enrollment in ACA exchanges becoming uninsured or utilizing Medicaid, further altering the financial landscape for EMS.

Action steps:

• Collaborate with municipalities and think tanks to assess impact
• Incorporate expected payer changes into your financial planning models

4. Hospital closures and “brown outs:” Operational consequences for EMS

With overall Medicaid and hospital reimbursement facing cuts, safety-net hospitals — especially in rural and underserved urban areas — may reduce services or close entirely. EMS agencies may experience:

• Longer transport times
• Increased interfacility transfer volume (IFTs)
• Higher ambulance patient offload times (APOT)
• Surge in low-acuity 911 calls due to loss of access to basic primary care

Action steps:

• Develop APOT mitigation protocols
• Implement or expand treat-in-place (TIP), telehealth, and mobile integrated health (MIH) models
• Tighten IFT intake procedures, pre-collect payments, and formalize payer contracts

5. Medicare reimbursement at risk via S-PAYGO

The act may trigger the Statutory Pay-As-You-Go (S-PAYGO) Act of 2010, leading to an up-to-4% across-the-board cut to Medicare reimbursement — potentially hitting EMS agencies already reeling from the Medicaid changes in the act. This is in flux, and Congress has the authority to waive implementation of PAYGO cuts for specific laws, and they have done so in the past. Stay tuned!

Action steps:

• Engage in federal advocacy for a waiver of the S-PAYGO rule
• Model and plan for potential Medicare cuts

6. EMS as employers: HR and tax changes on the horizon

The OBBBA also introduces employer-impacting provisions that require EMS leaders to coordinate with HR and finance departments:

• Overtime pay tax deductions (significant benefit for most employees who are not statutorily exempt from overtime, but it’s not a “raise”)
• Expanded dependent care flexible spending accounts (FSA)
• Permanent paid family medical leave and employer-provided childcare credits
• Student loan assistance exclusion extended
• Tighter I-9 enforcement

While many of these provisions may offer benefits or cost-savings to agencies and their employees, they also require careful implementation and management to avoid compliance issues or staff dissatisfaction.

7. A silver lining? Rural health transformation grants

A promising provision is the $50 billion Rural Health Transformation Program (2026-2030). While primarily aimed at hospitals, EMS agencies may find opportunities in partnerships for infrastructure and care coordination grants, and other sustainability programs, especially in rural communities.

Action steps:

• Collaborate with your rural hospitals now to ensure a seat at the table
• Partner with rural hospitals to secure participation and grant funding
• Collaborate with state officials to ensure EMS inclusion in grant design

Conclusion: The clock is ticking — plan for change NOW!

Many governors and state legislatures are already considering special sessions to respond to the far-reaching effects of the OBBBA. EMS leaders should actively engage with local policy makers, as well as state and national advocacy associations, to stay informed on how the legislative provisions within the Act will be implemented. Agency leaders should also model impacts of dramatic reimbursement changes; educate policymakers; and identify patient-centric, evidence-based options for system delivery changes that enhance economic sustainability and operational effectiveness.

The future of EMS as we know it may depend on the actions we take today to prepare for tomorrow.

Additional resources

Any questions, please reach out to us at info@pwwag.com. We are here to help. We can assist EMS agencies with modeling the impact of many of these changes and the impact they will have on your revenue cycle and operations, and assist in evaluating the overall impact of the OBBBA on your EMS or mobile healthcare agency.

• PWW|AG Webinar recording and handouts: “What the ‘One Big Beautiful Bill Act’ may mean for EMS” (Passcode: 4q5n#gmu)
• Full Text of H.R. 1
• Table of potential EMS Impacts by PWW|AG and NAEMT
• Healthcare provisions
• Paragon report: Addressing Medicaid money laundering
• Paragon report: California GEMT
• Office of Management and Budget (OMB) Letter May 2025 Stating Potential S-PAYGO Trigger
• OMB Letter July 2025 Indicating Potentially No S-PAYGO Trigger

The "One Big Beautiful Bill Act" Potential Impacts on EMS: A Wake-Up Call for Financial Sustainability

The One Big Beautiful Bill Act (OBBBA) has the potential to cause a seismic shift in how prehospital care is funded and delivered.

While the Act’s broader goals are aimed at deficit reduction and structural Medicaid reform, its cascading impact on EMS agencies—particularly those already walking the tightrope of financial sustainability—requires urgent attention and coordinated action by EMS agency leaders and advocacy groups.

PWW Advisory Group and NAEMT have collaborated on the development of a "living document" to highlight the potential revenue, human resources and tax implications of the OBBBA on the EMS system and our employees. 

This document will be updated periodically as we learn more about the Act, and its implications for our profession.

Click below for summary of the bill’s most critical provisions that have the potential to impact EMS agencies and recommended specific, strategic action steps EMS leaders should take to prepare for what could be the most disruptive fiscal environment in EMS history.

7-17-25 Table of Major Provisions in HR 1 That May Impact EMS.pdf

You can also click here to view and download the handout materials from a July 15, 2025 Pulse of EMS Finance webinar by PWW|AG and EMS|MC "What the “One Big Beautiful Bill Act” May Mean for EMS". Passcode: 4q5n#gmu

This is an excellent summary of the health-related provisions in the "One Big Beautiful Bill" (OBBB) from the Kaiser Family Foundation.

Click the link below to view the Bill's full text of the health-related provisions.

OBBB Healthcare Language.pdf

Health Provisions in the 2025 Federal Budget Reconciliation Bill

July 8, 2025

https://www.kff.org/tracking-the-medicaid-provisions-in-the-2025-budget-bill/ 

On July 3, the House passed the same version of the budget reconciliation bill passed by the Senate on July 1. On July 4, President Trump signed the legislation into law . This summary describes the health care provisions in the law (described as the Senate-passed bill) in four categories: Medicaid, the Affordable Care Act, Medicare and Health Savings Accounts (HSAs). It also compares the provisions to a earlier draft of the bill passed by the House on May 22.

Another example of the critical role EMS plays in rural communities!

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How Rural Communities Are Using EMS to Help Solve the Opioid Crisis

June 27, 2025

https://www.phi.org/press/calhealth-report-how-rural-communities-are-using-ems-to-help-solve-the-opioid-crisis/

“California is one of just five states in which the rate of death from drug overdoses is higher in rural areas than urban ones, according to data from the Centers for Disease Control and Prevention. The latest data from the California Department of Public Health shows that statewide, more than 7,800 people died from opioid overdoses in 2023, the most recent year statistics are available. While Los Angeles County recorded the highest total number of opioid-related overdose deaths in 2023 at 7,847, when adjusted for population size, Alpine and Sierra counties had the highest rates, though this data is less stable given the counties’ small total population size.

Because rural EMS units often rely on volunteer crews and face geographic barriers that force them to cover large distances in more varied terrain, response times are typically slower, according to the federal Centers for Disease Control and Prevention. In California, urban EMS providers also tend to receive more funding, resulting in a higher quality of care, according to the CDC. But across the state, emergency responders in rural regions are finding solutions tailored to their communities. Driven by a desire to help patients find long-term help for drug use, emergency providers are partnering with local organizations to connect patients with mental health care and treatment programs, as well as equip communities to distribute overdose-reversal medication.

Long-term treatment, from the ambulance

Sometimes, the long-term care that patients need includes mental health treatment; other times, it’s more directly related to substance use. For patients with opioid use disorder, medications, such as methadone and buprenorphine, can be an important tool. These medications, opiates themselves, mimic the effects of opioids to help prevent withdrawal symptoms without giving the patient a sense of “high.” Usually distributed under the care of a physician in a clinic or hospital, some EMS units are finding ways to start that treatment before patients even reach the hospital.

Following an overdose, many patients refuse to be transferred to a hospital, or they leave the hospital before a long-term care plan can be established, according to EMS Bridge, a program within California Bridge to Treatment, which works to use EMS services to advance community health. Either way, surviving an overdose can trigger painful withdrawal symptoms that have historically been difficult for medics to treat. But in the last few years, some EMS units across the state and country have experimented with providing medications that help withdrawal symptoms in the ambulance before patients even reach the hospital.

In 2019, clinicians at Cooper University Health in Camden, New Jersey, began a groundbreaking experiment. They trained paramedics to begin treatment with buprenorphine in the ambulance, a practice that had historically been limited to physicians in a clinic. It was a massive success: patients who were offered methadone or buprenorphine pre-hospital were six times as likely to use it, vastly increasing their chances of long-term treatment. Clinicians in California began wondering if they could bring the same success to their communities.

Beginning with a small pilot project in Contra Costa County in 2020, EMS Bridge, a program of the Public Health Institute’s Bridge Center, began a program to train EMS professionals to administer buprenorphine through funding from CARESTAR. “If you have an overdose and survive it, you have a 10 percent change of dying within a year,” said Dr. Gene Hern, medical director for EMS Bridge and associate clinical professor of emergency medicine at UCSF. But treatment with buprenorphine can lower that mortality rate by 70 percent—a success that Hern said is unparalleled within emergency medicine.

According to the Department of Health Care Services, 1,300 paramedics across 13 California counties have been trained to administer buprenorphine in the ambulance, and with new funding, Stanislaus County will be next. Hern said that adoption in rural California can be limited because patients will need a reliable, accessible place to continue getting medication once transferred. But he sees some strengths in rural areas as well. Longer transport times can mean that medics have more time to connect with their patients, establishing a trusting relationship in which a patient may be more open to starting buprenorphine.

Being able to help patients find long-term care helps medics, too, said Vanessa Lara, EMS Bridge Program Manager. While quantitative data is difficult to collect, she said their surveys indicate that being able to watch a patient transform before their eyes helps medics feel more satisfaction in their work, as does knowing that they helped put them on a path toward long-term healing.”

Click on the link below to read the full article.

How Rural Communities Are Using EMS to Help Solve the Opioid Crisis.pdf

All the way back in 1907, the American Medical Association published this editorial in their journal.

Key Quotes:

"One feature of the accounts of ambulance accidents is that in the majority of cases the ailment of the sufferer who is being taken to the hospital is not such as demands speed to save either life or suffering."

"The rushing across avenues crowded with traffic should never be permitted except under the most urgent conditions, and those absolutely known beforehand and not merely presumed on general principles."

"… a reduction in the number of accidents to ambulances must come rather from stringent enforcement of certain precautionary regulations rather than from renewed efforts to have the right of way…"

"It is needless to remark that such stringent regulations should be enforced with regard to ambulance service as will lessen the number of accidents."

Highlights - JAMA Editorial 1907.pdf

Mass. EMS bills a first step to speed up ambulances and save lives

By Angela Mathew

June 25, 2025

https://www.bostonglobe.com/2025/06/25/metro/mass-ems-bills-first-step-speed-up-ambulances-save-lives/

“The EMS system in our state is broken,” Feeley testified Wednesday at a hearing on the Legislature’s Joint Committee on Public Health. “Unfortunately, I witnessed its failures firsthand.”

An EMT at the hearing teared up listening to Feeley’s testimony during the hearing that addressed several pending bills related to local public health and emergency services.

Some municipalities, such as Boston, are large enough that they operate their own EMS services.

However, around 80 percent of the state’s licensed ambulances are operated by private companies that bid for the right to serve each town’s population, the Globe previously reported.

Those private companies have not been able to hire and maintain adequate staff, which has led to ambulance delays, according to the Globe’s coverage.

The state also doesn’t have a centralized system to coordinate ambulances and send them to another town in case of a shortage.

A slate of bills intends to address the delays, most notably by designating EMS as an essential service in the state, and would create a fund to pay for its operation, according to the bill posted online.

Other legislation would set up a committee to oversee EMS and to pilot a program for EMS workers to

treat patients “in place,” instead of driving them to the hospital, when appropriate.

Other bills discussed at the hearing propose requiring that all 911 dispatchers in the state be trained to instruct people how to do CPR over the phone and creating a database that lists defibrillators across the state.

The bill to make EMS an essential service proposes creating a fund to support EMS agencies and pay for things such as training, equipment, vehicles, and personnel salaries.

Representative Leigh Davis, a Democrat of Great Barrington, who sponsored the bill said that for too long, EMS has been underfunded and is not always covered by patients’ insurance.

“In 1973, the federal EMS Act left it up to the states to fund EMS, never recognizing it as an essential service,” Davis said. “Unlike police and fire, there’s no guaranteed funding, just donations, inconsistent local budgets, and low insurance reimbursement rates.”

Mike Woronka, chief executive officer of Action Ambulance, a private company, said that as baby boomers retire, his company has found it difficult to fill EMS positions, making existing employees’ jobs harder.

“We are beyond the crisis stage, it is affecting our staff, and it’s affecting the residents of this Commonwealth,” Woronka said.

Tina Dixson, an advanced EMT who has worked for 27 years in the Central Massachusetts towns of Hubbardston and Holden said she supports the bill to create a special commission on EMS.

“If you pictured an EMT in a neatly pressed uniform, working … with the calmness and precision of a NASCAR pit crew, but with the bedside manner of Mr. Rogers, that isn’t always the case,” Dixson said, “We need a lot of assistance with some of the things in these bills.”

Dixson also spoke in favor of bills creating a database for defibrillators so that people can locate one close to them in cases of emergency.

Matt Zavadsky, a past president of the National Association of EMTs, said he supports the designation of EMS as an essential service, but noted the bill does not identify a funding source.

Zavadsky said that it would be better for the state to designate EMS an essential service, and require localities to fund operations based on their own needs.

“Should the state set a standard that in rural areas in the Berkshires the response time should be 12 minutes?” Zavadsky said. “And do they pick the provider they’re going to contract with to provide that service? … It [should be] up to the local community to decide that.”

For the bill proposing a pilot program for EMS workers to treat people “in place,” Zavadsky said there needs to be an emphasis requiring insurers pay for treatment in place as opposed to only covering transportation to a hospital.

“Treatment in place is already proven, there’s enough data out there to show that it’s safe and it saves money,” he said. “Payment models drive clinical practice, so we need the bill to require that insurers pay for treatment in place.