News & Updates

Small Connecticut towns struggle to keep up with emergency calls as staffs dwindle

By Susan Danseyar,

Staff Writer

June 23, 2024

https://www.ctinsider.com/journalinquirer/article/ct-ems-calls-volunteer-emts-response-times-19487921.php

First responder Ryan Litwin says he chose to live in Litchfield because of its fire department, and wonders how many people would pick a community to live in because of its access to emergency services.

"I love the department and grew up with it, volunteering with it for years," said Litwin, who serves as the chief of the Bantam Fire Company, which provides services to the town along with the Litchfield Volunteer Ambulance. "That's actually one of the major reasons why I decided to buy a house here."

Everyone he knows says they appreciate volunteer firefighters and emergency medical technicians, Litwin said, "but do we really understand their challenges and sacrifices?"

Litwin said he's concerned about the number of volunteer first responders — who have to leave families and jobs "at the drop of a hat" — possibly dwindling in Litchfield some day. It's an issue that could very well have an affect on service and response times.

He joins a number of emergency medical service providers in small, rural Connecticut communities who say it's a challenge to keep up with increased call volumes while seeing decreases in available staff.

On the opposite side of the state, towns in the northeastern quadrant are definitely "feeling the pinch" of attracting and maintaining personnel for emergency services, said Tyler Millix, executive director of Tolland County Mutual Aid Fire Service Inc., which provides 911 services to 17 towns encompassing 34 emergency service organizations within Tolland, Windham, and Hartford counties.

More calls, fewer staff

Data supports Millix's claim in regards to a number of Connecticut agencies. According to the state's Office of Emergency Medical Services, EMS providers throughout the state responded to anywhere from 55,000 emergencies in April 2020 to 83,000 in December 2022. Of the 396 EMS providers in the state, over 40 of them saw their number of active crew members drop.

Stratford lost 83 active crew members over a two-year period, dropping to 94 by 2022. The Suffield Volunteer Ambulance Association lost 42 active crew members, with EMS personnel dwindling to 77 in 2022. And Enfield Community Ambulance lost 16 active crew members, going down to 46 by 2022.

OEMS's 2023 report is awaiting final approval and will be ready within a month or so, according to data manager and epidemiologist Eliza Little, but the 2022 data is the most recently available now.

"Every town is facing increased call volumes and decreased manpower, whether that's volunteer or paid people," Millix said. "It's becoming harder and harder to find people to become contributing members of the organization."

Former Somers Fire Chief John Roache, who is now heading Mansfield's department, told officials in March his department once had a roster of volunteers who would stay for years, but turnover has become faster while call volume for advanced life support keeps going up — both in town and the several area communities where his personnel provide advanced life support. The Board of Selectmen allocated $20,000 in the 2024-25 budget for a campaign to retain and recruit volunteer firefighters. 

Interim Somers Chief Keith Allard, who took over for Roache in May, has been a volunteer firefighter with the department for over 40 years. He said EMS calls are the most frequent for the department, with between 1,000 and 2,000 each year. The number his staff respond to in town and for other communities has increased substantially in the last 10 years, Allard said.

Stafford officials formed an Emergency Services Commission for directors of the town's two fire departments and ambulance company to discuss the best ways in the future to handle the growing demand for all calls, including EMS.

West Stafford Fire Chief Joe Lorenzetti said there's definitely been an increase in calls for EMS and fire/rescue incidents. About 10 years ago, he said the departments received 900 to 1,000 calls a year. In 2022, that number increased to 1,024, and to 1,400 in 2023. For 2024, Lorenzetti said he's anticipating the call volume will be between 1,600 and 1,700 calls.

Alex Moore, director of the Stafford Ambulance Association, said his personnel are currently answering about 1,750 calls, averaging about four or five a day, that include advanced life support and mutual aid. To meet needs, he said the goal is to have two people on duty at all times. However, Moore said, it's a struggle to find qualified EMTs and retain them.

The hourly wage for EMTs is $17.50 an hour, said First Selectman William “Bill” Morrison, who is also assistant chief of the West Stafford Fire Department. He pointed out less dangerous jobs such as working in the food industry pay that same wage. EMTs must also undergo extensive training that's not only time-consuming but also expensive, he said.

Litchfield EMS calls are covered by the all-volunteer Bantam Fire Company and Litchfield Volunteer Ambulance, which is staffed by a combination of volunteers and staffing service employees.

Litwin said both services have seen a dramatic increase in EMS call volume over the years, attributing it to aging baby boomers and an increase in housing for older residents in the area.

"Those are what I would call a target hazard," he said. "They significantly increased the call volume because of being a health care facility or having agin

The Bantam Fire Company has 70 firefighters, and 30 EMTs with some personnel serving as both. It's a close "brotherhood" with volunteers as the agency's backbone, Litwin said.  However, he said every single agency in the country is not where it wants to be in terms of recruiting and retaining personnel.

"Even if you have enough, you always want more," Litwin said. 

Bantam has a very strong membership, Litwin says, but in the summer, many people are often away on vacation. "It doesn't take very much to upset the balance." 

Litwin said the two agencies are keeping up with demand and actively trying to recruit people. "But we are concerned," he said. "We have some young people and older people who are the most reliable but they're aging out." 

He said it's not true that people don't want to volunteer anymore. "Litchfield is busier than many agencies and just needs more volunteers."

Response times

Another challenge for EMS providers is that the very nature of such calls demands immediate attention or, at the very least, as quick a response as possible. 

According to OEMS data from 2020-22, urban towns had the most calls at 483,913, with the shortest average response time of 7.39 minutes. Suburban towns had 95,789 calls with an average response time of 8.12 minutes. Rural towns had the fewest calls at 89,895 yet the longest average response time of 10.7 minutes.

About nine minutes was the average response time across Connecticut for EMS calls in 2022, according to OEMS data. Response time is calculated from the moment dispatch notifies an agency of an emergency to the moment a crew arrives on the scene.

New London, at 5.01 minutes, had the fastest average response time in the state, according to OEMS' most recent data. Washington, at 18.82 minutes, had the slowest average.

OEMS data for average response times takes into account outliers such as weather and transport delay because of traffic.

OEMS reported Somers, with one fire station, had an average response time of 6.02 minutes for EMS calls in 2022.

Allard recently compiled data for the past six months. There were 488 calls in Somers with a response time of 5.50 minutes. The 202 mutual aid calls to Stafford during the same time period had a response time of 11.13 minutes; for the 16 calls to Enfield, response time was 9.25 minutes; and for the 63 calls to Ellington, response time was 9.55 minutes, he said. The department made 5 calls to East Longmeadow, Massachusetts, with a response time of 10.57 minutes.

Stafford, with two fire stations, had an average response time of 10.70 minutes for EMS calls in 2022, according to OEMS data. Moore said calls in town are currently averaging about nine to 12 minutes.

One of the particular challenges for Stafford's response times to calls lies in its geography. Stafford is the third-largest town in the state by acreage, Morrison said.

"We have 54 square miles," he said. "Certainly, the distance around town makes a difference because we can get out the door fast but have a longer ride than many towns to our destinations." 

The town of Litchfield, with five fire stations, is also quite large in terms of land, with 56 square miles, Litwin said. 

The average response time for EMS calls in Litchfield in 2022 was 8.08 minutes.

"Regardless of fire or rescue, fast response times are always what we want but is that realistic?" Litwin said. "I can have staff and the ambulance in my fire station but the furthest point of my district is still over 12 minutes away and that's just driving time in good weather."

Interesting perspective... Community and EMS system leaders should carefully evaluate current evidence-base practices and re-design EMS systems for success and sustainability.

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Multnomah County (OR) Ambulance Crisis: By Design or Mistake?

Multnomah county has turned a contracting failure with AMR into an ambulance crisis, writes Stephen Dean, PhD.

Stephen Dean, PhD

06.19.2024

https://www.jems.com/commentary/multnomah-county-or-ambulance-crisis-by-design-or-mistake/

The Failsafe Franchise

EMS pioneer Jack Stout created the Failsafe Franchise in the 1980s when he was hired to fix the ambulance service in Fort Worth, Texas. He designed the model to produce clinical quality and economic efficiency through contract provisions that use competition in the wholesale market to ensure the lowest cost; and then make available an ingenious set of provisions to hold the winning ambulance bidder accountable for the promised performance.⁵

The Accountability provisions are designed to ensure that should an ambulance provider be unable to perform, it can be replaced overnight without any degradation in service to the patients. The Failsafe Franchise ensures accountability through two key contract provisions: first, the 3 Way Lease, and second, the process to determine if an ambulance provider has failed to meet its contractual obligations.⁵

The 3 Way Lease

Jack Stout was the first person to use the 3 Way Lease in EMS contracting. It simply requires a contractor to lease all its ambulances and equipment in a manner that allows the contracting entity to acquire all this equipment by assuming the lease payments if the contractor is terminated. This arrangement prevents unscrupulous ambulance companies from holding patients hostage by threatening to abscond with the system’s infrastructure if the company is replaced.⁵

Contractor Due Process

The second innovation protects the ambulance provider along with ensuring accountability, by providing due process in the form of required notifications of violations of contract provisions as well as opportunities to provide correction plans to fix violations. The replacement of an ambulance provider through the declaration of “material breach” is the county’s ultimate tool to ensure accountability.

Jack Stout advocated for the use of private ambulance companies because, unlike fire departments or publicly operated ambulance services, they could be replaced. He famously, or infamously, said the biggest advantage of using a private company is that they are easy to fire if they do not perform. 

Failed Bid Process

In 2018, the Multnomah County (OR) Health Department conducted a competitive bid using a Failsafe Franchise system design. AMR was the incumbent provider with a history of more than 20 years providing eight-minute response times with 90% reliability to life threatening emergencies with Advanced Life Support (ALS) ambulances staffed with two paramedics each, as required by their contract with the county.⁴

In addition to those requirements, the request for proposal (RFP) contained over a hundred other requirements and deliverables including live monitoring of the system and reporting of response time and clinical performance.⁶ With no indications that the county was in the least dissatisfied with the incumbent provider and such a daunting list of clinical demands, there was only one bid submitted, that of the incumbent.⁷

When AMR and the county completed their negotiations to set the rates patients would be charged by AMR, the rates were the highest in the county’s history. The county agreed to an immediate 34% increase in rates and annual rate increases based on the CPI of up to 5.5% per year. These annual rate increases were automatic and not dependent upon AMR even meeting the minimum standards in the contract.⁷

By attracting only one bidder, the county effectively negated the provisions for obtaining a competitive rate.

Including the initial 34% rate increase, ambulance rates have increased by 70% since the county entered its contract with AMR in 2018. For the past two years patients have seen rates go up even though the county and AMR both agree that the service patients are currently receiving is substandard.⁸

This bid failure should have been a warning to the county that should AMR fail to perform, it might be difficult to find another provider that could meet the county’s stringent standards, particularly its unusual minimum staffing requirement of two paramedics per ambulance rather than one paramedic and one EMT.

Contract Renewal Failure

While AMR remained in compliance with response time standards in late 2021, it had become evident that increasingly longer response times were occurring because of a staffing shortage that was getting worse each month. The county had an opportunity to address this issue, and rate issues, with AMR prior to the expiration of the AMR contract in August of 2023.⁶

Though the original contract had a five-year term, it allowed the county to make an offer of renewal at the county’s sole discretion. That renewal offer however had to be presented to AMR at least 18 months prior to end of the initial five-year term, making it due before March 1, 2022.

The county made the offer to renew 17 days late. The County Board of Commissioners (Board) held no hearing, received no briefing, and voted to approve the renewal on its consent agenda, where multiple routine or inconsequential items may be approved with one vote.⁹

The county’s EMS Office Staff submitted a misleading “Agenda Placement Request”¹⁰ which stated in part, “Contractually, if AMR performance measures are met, an extension of an additional five years shall be issued.”

According to the contract, however the request should have stated, “Contractually, if AMR performance measures are met, an extension of up to an additional five years shall may be issued.”⁶

Why the staff did not just copy the exact contract language is not officially known.

Commissioner Sharon Meieran, MD, JD, who has been an outspoken advocate for patient care and at odds with both the EMS Office and County Chair for their inept handling of the staffing crisis told the press, “The fact that renewal of the ambulance contract was done as a ‘consent agenda’ item is so bizarre as to suggest a conscious intent to hide this from the board. And it succeeded.”⁹

To date the EMS staff have not commented on the contract renewal or the misrepresentations during the process.

The renewal process was the county’s last opportunity to negotiate on equal terms with AMR about staffing and rate concerns that were, or should have been, evident from the increasingly longer response times each month due to the national paramedic shortage.

Instead, the Board approved the contract renewal on March 17 and just two weeks later, AMR was out of compliance with the contract’s response time standards, and has been ever since.¹¹ The county threw away the opportunity to address staffing and rates in a renewal negotiation.

Failure to Fine and Failure to Replace the Contractor for Material Breach

The Failsafe Franchise contains two types of penalty provisions: fines for long response times; and replacement of an ambulance provider for major failures to meet contract standards, including repetitive failures to meet monthly response time standards.⁶

The fundamental problem causing the substandard response times is a lack of staffing for AMR ambulances. And the reason AMR lacks staffing is because it cannot retain, nor recruit, enough paramedics due to the ongoing national shortage of paramedics which started after the pandemic.⁸

Changing the staffing requirement temporarily to a minimum of one medic and one EMT would allow AMR to keep all its units staffed until the paramedic shortage ends because there is no shortage of EMTs. Every other county in Oregon allows ALS ambulances to be staffed in this manner as do all the surrounding counties in the state of Washington.¹²

The county has expressed concern that two paramedics are needed on cardiac arrests and that area first responders are not always able to send a paramedic to these calls. Requiring AMR to send two ambulances to cardiac arrest calls, however, would be simple enough with a fully staffed system.

There are approximately seven hundred cardiac arrests a year out of 120,000 responses. It also turns out that in 2022 fire paramedics were present at 99.9% of the cardiac arrests in the city of Portland where most of the county’s arrests occur. The sole exception was a witnessed arrest in an ambulance in route to the hospital. So, the actual number of two ambulance responses required would be much less than seven hundred.¹³

The county’s medical treatment protocols require rapid transport to the hospital of patients suffering from strokes, heart attacks, trauma, and childbirth complications for optimal care. The county monitors the length of time ambulances are on scene at these types of calls to ensure that patients arrive as soon as possible at the hospital to receive time critical care or surgical interventions. Long response times contribute directly to delays in getting these patients the care they require.¹⁴

Failure to Fine for “Outlier” Response Time Violations

The county had earlier started chipping away at the Accountability provisions of the system design by not fining AMR for dangerously long response times, referred to as “outlier” responses, starting in the first year of the Contract. The Contract defines these long response times for Code 3 (life threatening emergency) calls as 13 minutes or greater in urban areas and 25 minutes or greater in rural areas.⁶

The purpose of the outlier fines is to discourage AMR from providing extremely long response times to a few unlucky patients to maintain overall compliance.

AMR and the county cited the paramedic shortage in 2021 and 2022 as a reason for outlier response times. But by forgiving the fines for these long responses, the county created an incentive for AMR to scrape by on compliance at the expense of these few patients who received the very long response times.¹⁵

Failure to Declare Material Breach

According to the accountability provisions of the Failsafe Franchise, if an ambulance provider fails to perform, the contracting jurisdiction can replace the provider after notifying the provider of its failure to perform and offering the provider the opportunity to correct the failure.⁵

Repetitive noncompliance occurs if AMR fails to meet response time compliance three months in a row. If the company fails to correct the compliance the county can declare AMR in Material Breach and initiate the replacement of AMR with another provider. However, the county has “sole discretion” to determine “Material Breach,” so the county has leeway about whether, and when, to invoke these provisions.⁶

The county issued a notice of repetitive noncompliance in August 2023 after 18 months of noncompliance and after AMR’s corrective plan to improve paramedic recruiting and use basic life support (BLS) Ambulances to improve response time performance failed. The county notified AMR it would begin fining the company, as well.¹⁵

In November 2023, the county fined AMR over $500,000 for long response times that occurred in a single month, August 2023. The county’s Health Director also announced that the county was not interested in replacing AMR.¹⁶ AMR promptly appealed the fines to that same Health Director as specified in the Contract. He denied the appeal, but AMR has still never paid any fines.¹⁷

The county has not presented medical research or evidence that shows a benefit to patients of two paramedics over one paramedic absent rapid response times. In fact, the research presented by the county and AMR show the opposite, that response times are much more significant than the presence of a second paramedic.¹⁸

Failsafe Franchise or County to Blame?

The county had effectively abandoned the Failsafe Franchise system design by the end of 2023, including its provisions for guaranteeing low rates through bid competition and quality through its system of fines and provisions for contractor replacement.

In every instance, it was the county that circumvented or just ignored the safeguards in the model; the same safeguards which were incorporated into its RFP and contract with AMR, to guarantee performance accountability and fair, competitive rates.

After the summer of 2022, rates continued to increase annually even as AMR’s compliance with the standards upon which those rates were based continued to plummet. As personnel costs decreased by millions of dollars per year due to the staff shortage, there was an opportunity instead for AMR to reap enormous windfall profits.

The Board of Commissioners voted in February 2024 not to take immediate action to address the long response times and poor EMS quality that exists today but did approve a plan to study the problem over the next year.¹⁹ That plan also includes mediation with AMR apparently to prevent the implementation of the one medic, one EMT staffing solution proposed earlier by AMR which was endorsed by every EMS first responder organization and every city in the county.

County Commissioner Sharon Meieran expressed her frustration with the board’s inaction in December 2023.

I would just conclude then that the herculean effort to avoid talking about ambulance response and emergencies is mind-blowing to me, and I just watch it happening. And as a board, I think our responsibility is to hold the chair to account in terms of bringing things to the attention of the people for board meetings and allowing us to discuss what is literally costing lives of Multnomah county residents every day that you fail to act.²⁰

The cause of the Failsafe Franchise model’s failure in Multnomah County is the Board’s forfeiture of its ability to hold AMR accountable. This is because the EMS medical director has refused to adapt the staffing standard to the reality of the national paramedic shortage in Oregon. AMR cannot be replaced, because no other ambulance provider in the country can simultaneously meet the county’s response time requirements while also meeting the county’s stringent two-paramedic staffing requirement.

To date, based upon the recommendation of the county’s EMS medical director, the county chair and two lame duck commissioners whose terms will end in December have blocked all attempts to change the staffing standard to address the ambulance shortage, the latest vote taking place on June 6, 2024. This vote affirms the continuation of the county policy of harming patients and enriching AMR.^{19, 21}

Were just one of these four persons to change their position, the ambulance shortage could end, and contractor accountability be restored.

Editor’s Note: This commentary reflects the opinion of the author and does not necessarily reflect the opinions of JEMS. 

References

1. Watson, E., A Portland Man Died Waiting for an Ambulance that Didn’t Arrive for 32 Minutes:. 2023, KGW-TV: Portland, Oregon

2. Pederson, J.V., Chair Jessica Vega Pederson Announces Four-Point Plan to Address Ambulance Service Crisis. 2024: Portland, OR

3. Haas, R., AMR Pressures Multnomah County Over Ambulance Staffing Rules. 2024: Portland, OR

4. Lewis, M., Paul; Deputy Health Officer, Multnomah County, D.E.A. Knott, Multnomah County, and M. Oxman, Gary; Health Officer, Retired, Multnomah County. Multnomah County Emergency Medical Services Planning and Procurement Project Kickoff. [Web] 2017 2024/01/01 [cited 2024 January 11, 2024]; Available from: https://multco-web7-psh-files-usw2.s3-us-west-2.amazonaws.com/s3fs-public/EMS_project_kickoff_slides.pdf.

5. Stout, J., The Failsafe Franchise. Journal of Emergency Medical Services, 1985. 10(10): p. 56-58.

6. Multnomah County, O., Multnomah County Services Contract Agreement for Exclusive Ambulance Service Contract # 5600002522. 2018: Portland Oregon. p. 56

7. Multnomah County, O., Board Approves New Five-Year Contract for Ambulance Services. 2018, Multnomah County, Oregon: Portland, Oregon

8. Lewis, M., Paul, R. Lauer, and D. Schappe, Perspectives On Addressing Multnomah County Ambulance Delays Amid Staffing Woes. 2023, Oregon Public Broadcasting

9. Haas, E., ‘Consent Agenda’ Was Key to ‘Hide’ MultCo-AMR Contract Renewal. 2024: Portland, OR

10. Monnig, A., Multnomah County Agenda Placement Request. 2022: Portland, OR

11. Lewis, P. and A. Monnig, EMS Ambulance Services Briefing – September 19, 2023. 2023: Portland, Oregon

12. Legislature, O.S., Oregon Revised Statutes:  Chapter 682 — Regulation of Ambulance Services and Emergency Medical Services Providers. 2023: Salem, OR. p. 29

13. Haas, E., Paramedic Paradox: Unraveling Multnomah County’s Response Time Dilemma. 2023: Portland, Oregon

14. Jui, M., Jonathan; EMS Medical Director, Multnomah County, Patient Treatment Protocols  Section 10:  Treatment. 2024.

15. Pederson, J.V., Chair Jessica Vega Pederson: County Will Issue Penalties to Address AMR Performance Issues. 2023: Portland, Oregon

16. Pederson, J.V., Multnomah County fines AMR $513,650. 2023, Multnomah County Executive: Portland, OR

17. Del Savio, A., Tensions and Wait Times Rise During Multnomah County Ambulance Shortage. 2024, Pamplin Mediaw

18. Watson, E., Why Ambulance Provider AMR Says Multnomah County’s Emergency Medical System Is in a State of Crisis. 2023, KGW-TV: Portland, Oregon

19. Haas, E., ‘Sinking Ship’: MultCo Board Votes Down Immediate Action, but Passes Long-term Approach to Ambulance Crisis. 2024: Portland,OR

20. Haas, E. and A. Plante, Multnomah County Commissioners Meieran, Vega Pederson Clash Over Ambulance Staffing Crisis. 2024: Portland, OR

21. Nelson, T., Deputy Board Clerk, Board of County Commissioners, Multnomah County, Oregon, Minutes of the Multnomah County Board of Commissioners, Thursday, June 6, 2024,. 2024: Portland, OR

Interesting approach!

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Montana Creates Emergency ‘Drive-Thru’ Blood Pickup Service for Rural Ambulances

By Arielle Zionts

JUNE 17, 2024

https://kffhealthnews.org/news/article/montana-emergency-drive-thru-blood-pickup-rural-ambulances/

Crystal Hiwalker wonders if her heart and lungs would have kept working if the ambulance crew had been able to give her a transfusion as the blood drained from her body during a stormy, 100-mile ride.

Because of the 2019 snowstorm, it took 2.5 hours to drive from her small town of Lame Deer, Montana, to the advanced trauma center in Billings.

Doctors at the Billings Clinic hospital revived Hiwalker and stopped the bleeding from her ruptured ectopic pregnancy. They were shocked that she not only survived after her heart stopped beating and she lost nearly all her blood, but that she recovered without brain damage.

The Montana State Trauma Care Committee, which works to reduce trauma incidents and to improve care, later realized the ambulance that carried Hiwalker had passed near two hospitals that stocked blood. What if Hiwalker had access to that blood on her way to Billings, committee members asked.

That realization, and question, inspired committee members to create the Montana Interfacility Blood Network, which they say is the first program of its kind in the U.S. The network allows ambulance crews to pick up blood from hospitals and transfuse it to patients on the way to the advanced care they need.

“We kind of came up with the idea of having a blood handoff — like driving through a fast-food restaurant drive-thru — and picking up blood on the way,” said Gordon Riha, a trauma surgeon at the Billings Clinic trauma center, where Hiwalker was treated. Riha said timely blood transfusions can prevent death or permanent brain injury.

The network is aimed at rural patients, who face elevated rates of traumatic injuries and death, said Alyssa Johnson, trauma system manager for the state of Montana.

“We have to get more creative. We don’t have a blood bank on every corner, and we don’t have a Level 1 trauma center on every corner,” Johnson said.

Network leaders say the program has helped at least three patients since it launched in 2022. They hope it will be used more in the future.

Hiwalker is excited about the program.

“I’m so glad that something like this got started, because it would save a lot of lives from where I live,” she said.

Hiwalker said she has heard about people bleeding to death after car crashes, gunshot wounds, and stabbings in her rural community. Johnson said work injuries, cancer, gastrointestinal problems, and childbirth can also cause serious bleeding.

The Montana trauma committee began discussing the blood network a few months after Hiwalker’s brush with death. First, it created a map of 48 facilities with blood banks. Then, it created guidelines for how hospitals, blood banks, ambulances, and labs must communicate about, package, transport, document, and bill for the blood.

The network is used only during emergencies, which means there’s no time to test patients’ blood types. So it uses only type O red blood cells, which can be transfused safely into most patients.

The receiving hospital — not the one that provided the blood — is responsible for billing patients’ insurance for the blood. The cost depends on how much blood patients need but typically ranges from several hundred dollars to more than a thousand, said Sadie Arnold, who manages the blood bank at Billings Clinic.

Arnold said blood must be stored in a lab and managed by professionals with specific degrees, clinical experience, and board certifications.

Some rural hospitals lack space for a lab or money to recruit these specialists, Arnold said. Or they may not need blood often enough to justify storing a product that can expire and — especially during the current national blood shortage — is needed elsewhere. The network uses blood that has a maximum shelf life of 42 days.

Rural hospitals that do store blood may have only small amounts on hand. A rural Montanan with severe bleeding experienced that firsthand when he went to the nearest hospital, which had only one unit of type O blood, according to a report on the blood network. But thanks to the new program, ambulance medics picked up more blood from a hospital halfway through an 80-mile drive to the trauma hospital.

Ideally, rural patients with serious bleeding would be transported by medical helicopters or airplanes outfitted for transfusions. But, as in Hiwalker’s case, flying can be impossible during bad weather. That can mean hours-long ambulance rides. Some towns in northeastern Montana, for example, are more than 250 miles away from the nearest advanced trauma center.

“This was truly designed for kind of that last-ditch effort,” Johnson said. When “we’re out of options, we’ve got to get the patient moving towards a larger center, and we can’t fly.”

The blood handoff may involve the ambulance stopping at the second hospital, Johnson said. But during one incident, a police officer picked up the blood and delivered it to the ambulance at a highway exit, she said.

Ambulances may also pick up a paramedic or nurse to provide the transfusion along the way, since many rural ambulance crews are staffed by emergency medical technicians, who in Montana aren’t authorized to do so.

Medics in other cities and states, including ones with rural areas, have started performing blood transfusions in ambulances and helicopters, said Claudia Cohn, chief medical officer of the national Association for the Advancement of Blood & Biotherapies.

She said researchers are also interested in the potential of using frozen and freeze-dried blood products, which could be helpful in rural areas since they’re easier to store and have longer shelf lives.

Johnson said the Montana Interfacility Blood Network is the only program she knows of specifically aimed at rural patients and involving ambulances picking up blood from hospitals along their routes. She said the network is gaining interest from other states with large rural regions, including Oregon.

Hiwalker said receiving a blood transfusion in the ambulance could have prevented her near-death experience and the trauma her husband faced from seeing her suffer as he rode in the ambulance with her. She’s glad her ordeal led to an innovation that is helping others.

Protest erupts over ambulance contract for Kauai and Maui counties

by: Lucy Lopez

May 31, 2024

https://www.khon2.com/local-news/protest-erupts-over-ambulance-contract-for-kauai-and-maui-counties/

HONOLULU (KHON2) — A week following the Department of Health’s decision to award the ambulance contract for Kauai and Maui Counties to American Medical Response (AMR) after a competitive bid process, a protest has emerged.

Falck USA, the unsuccessful bidder, filed a formal notice of protest Friday, citing alleged errors in the calculation of their scores and inconsistencies in the evaluation criteria utilized for the contract awards.

STATEMENT FROM TROY HAGEN, CHIEF COMMERCIAL OFFICER FOR FALCK USA

“We filed a notice of protest after identifying what appears to be a clear error in calculating Falck’s scores, along with inconsistencies in the evaluation criteria used to award the contracts. We look forward to opening discussions with the Department of Health and ensuring these vitally important emergency medical services contracts are awarded based on a fair and transparent process.

Falck continues to stand ready to serve. As a foundation-owned healthcare provider, we would bring a fresh perspective, unmatched financial stability, reliable services developed around global best practices, and a deep commitment to delivering the highest quality care to the communities we serve.”

This marks the second time that the ambulance bid process has faced protest.

In August of last year, Falck was initially awarded the contract, but AMR filed a protest, prompting the Department of Health to restart the bidding process.

In response to the latest protest, the Department of Health stated that it cannot proceed with the contract award until the protest is resolved and declared that it will refrain from further comments on the matter at the time.

The protest introduces a new twist in the ongoing saga surrounding emergency medical services in Kauai and Maui Counties, leaving stakeholders and residents awaiting a resolution to ensure timely and effective ambulance services in the region.

The work begins for county run EMS

Emergency Medical Services in Henry County could transition from Henry County Health Center to the county itself

AnnaMarie Ward

Jun. 5, 2024

https://www.southeastiowaunion.com/se-iowa-union-mount-pleasant/the-work-begins-for-county-run-ems/

MT. PLEASANT — Henry County Supervisors approved and adopted the third and final reading of a resolution which declares emergency medical services as an essential county service in Henry County.

If all goes well and voters approve the tax levy this November, Emergency Medical Services will become a Henry County entity.

“The Board hereby declares EMS to be a central county service in the county and hereby directs that any and all other actions be taken as necessary to proceed with the process under Iowa Code 422D.1 to declare EMS an essential county service,” Supervisor Greg Moeller read from the resolution at Thursday, May 30 Board of Supervisors meeting.

“Now the work begins,” Henry County Health Center Chief Financial Officer David Muhs said following the board’s approval.

According to the resolution, these “other actions” and additional work will include creating a County EMS System Advisory Council, “to assist in researching and assessing the service needs of the county and guiding implementation with respect to the potential imposition of a local options income surtax and/or ad valorem property tax for EMS in the county.”

While declaring EMS an essential county service means the county will foot the bill, it does not mean the entire cost will be passed onto taxpayers.

According to Muhs, the approximate cost of operating the EMS service currently is $2.4 million and the service is receiving about $2.2 million in revenue. Muhs states this revenue has been consistent percentagewise over the last five to 10 years.

Discussions with the Board of Supervisors revealed a cap on tax levy ability for EMS will be 75 cents per $1,000 valuation.

According to Moeller, it will be the responsibility of the County EMS System Advisory Council to “Bring it to the public to let them know that the 27 cents that the hospital now levies for ambulance services will be included in this 75-cent levy.”

Included in this 75 cents however, will be the 27 cents per $1,000 valuation already implemented in the Henry County Health Center’s general basic levy. These 27 cents will be rolled into the total 75 cents and taken out of the hospital’s levy.

Wayne County Commission seeks temporary EMS solution until levy takes effect

by: Jessica Patterson

Posted: Jun 10, 2024

https://www.wowktv.com/news/west-virginia/wayne-county-wv/wayne-county-commission-seeks-temporary-ems-solution-until-levy-takes-effect/

WAYNE COUNTY, WV (WOWK) – The Wayne County Commission says a newly passed levy will help emergency response in the county, but they’re working on a plan to help until that levy takes effect next year.

The Wayne County Public Service Levy, designed to help improve emergency services, passed in the Primary Election in May by just one vote. Initially, it appeared the levy would fail, with just 59.9% of the needed 60% vote. However, once all mail-in ballots were accounted for and after canvassing, the levy pulled through by one vote.

The Wayne County Commission took to social media this Sunday to thank those who voted in support of the levy.

“No matter how you voted, your political affiliation or your community, the passage of this levy will benefit each person in the county at a very reasonable cost,” said the Wayne County Commission. “According to the commission, the average property owner will pay less than $100 per year for this improved service.”

‘It’s a problem we inherited’: Wayne County Commission talks solutions to EMS issues

They say one goal of the levy is to create a 24/7 county-run EMS system to alleviate the county’s slow ambulance response times. Residents in the area have told 13 News the problem with response times gives them a helpless feeling after multiple instances where families have called 911 only to be told an ambulance isn’t readily available.

Commissioners say the levy will begin providing funding for EMS and other services in July 2025. The commission also says they are working to implement a temporary strategy to improve emergency response times until the levy takes effect.

Colorado Springs' proposed city-run ambulance service voted down

By Mary Shinn

Jun 11, 2024

https://gazette.com/news/colorado-springs-proposed-city-run-ambulance-service-voted-down/

The Colorado Springs City Council voted down a new city-run ambulance service Tuesday after months of debate about whether to take over services provided by a private company.

The council voted 5-4 not to create an ambulance service that would have been funded through fees for service, not city taxes. The vote leaves the contract with American Medical Response in place.

Colorado Springs Fire Department Chief Randy Royal recapped the pitch for bringing the ambulance service in-house during the meeting, saying it would be self-sustaining, the city could bill patients less and it would allow the department to continue adding innovative services for low-level and behavioral health calls. The department has been recognized for unique services. For example, crews in SUVs respond to 911 calls for low-level injuries such as sprained ankles that free up others to respond to critical emergencies.

Councilwoman Lynette Crow-Iverson was among the council members that opposed the project and pointed to an audit report that came out Thursday as proof the Fire Department was over-estimating its revenues from commercial insurance. As a city enterprise the service would have to pay for itself through Medicaid, Medicare and commercial insurance payments. Private insurance brings in the highest amount of revenue for ambulance services.

The audit found on average comparable cities bring in about 14% of revenues from commercial insurance companies, while the Fire Department estimated about 23% of revenues could come from commercial insurance.

"Their estimations were over significantly," Crow-Iverson said. She opposed the project along with councilmembers Dave Donelson, Mike O'Malley, Brian Risley and Michelle Talarico.

As an enterprise fund, the city could not backfill any revenue shortfall with tax revenue.

Crow-Iverson said the city did not have the start-up funding for the service in hand and did not provide the council with the letters of intent from donors. It was a point that Royal disputed, saying the city had monetary commitments. But officials thought it would be premature to collect the money from donors before the council voted on the issue, he said. 

The audit also found a cash-flow risk with the proposal.

"Given start-up costs, the uncertain actual payor mix, and the lag from time of service until cash is received, the EMS enterprise would rely upon available start-up cash during initial operations," the audit said.

Crow-Iverson also noted that when AMR did not meet the city's time limit requirements for responding to 911 calls it was by two or three minutes and that will be solved as the agency hires additional people. The company faced a shortage of employees following the pandemic.

"The free market will get back up to speed," she said.

Councilmembers in favor of the project said they were willing to accept some risk in favor of allowing the Fire Department to innovate and potentially provide faster services 

"People’s lives matter and responding to their critical moments should be and should always be our top concern," said Councilmember David Leinweber.

AMR has struggled to meet the city's required response to emergencies. 

Data show the company paid the city more than $5.7 million in fines — largely for delayed response times — between April 2020 and January 2024.

The city was expecting to start up its new EMS service April 1, 2025. Now, the city could put out a call for companies to apply to provide services, known as a request for proposal. AMR could be among the companies to apply and could renegotiate its contract at that time.

Mayor Yemi Mobolade, Council President Randy Helms and Royal all said they were disappointed in the council's decision in a news conference on the steps of City Hall.

"This does set us backwards, we are not advancing," Mobolade said. "... We have got to innovate. We got to be better. We can't just do things the same way."

Royal said by relying on a private company to provide services the community has left $35 million in Medicaid payments on the table that could bolster emergency response.

AMR does not qualify those payments as a private company. 

The Fire Department argued earlier in the year it could put would-be profits into services that could improve patient experiences and pay employees better. The department expected that if it had taken over the service it would have hired mostly AMR employees.

After nine years, the department expected to have $42 million in the bank.

"This has been the most scrutinized project I have ever been involved with," Royal said during the meeting. 

The move to in-house services also had support from the local firefighter and police associations and Dr. Robin Johnson, the medical director for El Paso County Public Health.

Curt Crumb, president of Colorado Springs Professional Firefighters union Local 5, said the current for-profit ambulance model holds the community back from world-class care.

"If we continue in the current fashion, we will always have a competing interest," he said.

Like hospital emergency departments, EMS agencies are safety net providers, responding to all patients who access 911, regardless of the patient’s socio-economic status. Often, EMS agencies provide medical care to these patients, but are not compensated for those services, either by insurers, or the patients themselves (uninsured/self-pay).

Uncompensated care exacerbates the on-going financial crisis in EMS, which is a key driver of the EMS staffing crisis. An industry news tracker has chronicled over 2,000 local and national EMS news reports since 2021, and 82% of the news reports highlight the EMS economic and staffing crisis.

The Academy of International Mobile Healthcare Integration (AIMHI) and the National Association of Emergency Medical Technicians (NAEMT) recently distributed a survey related to the impact of uncompensated care in EMS. 28 agencies representing diverse types of EMS systems in both urban and rural communities responded to the survey. PWW|AG analyzed the data provided by the respondents and has summarized the findings.

Download the summary report here.

Download the data set here.

The results from the survey detail the level of uncompensated care provided by the respondents, and we applied these finding to the U.S. EMS systems to quantify the likely cost of unreimbursed care to America’s EMS agencies.

Findings:

• Data from survey respondents for 2019, 2021 and 2023 reveals that self-pay patients represent 13.3% of the overall patients treated by the EMS agencies that responded to the survey.
• • For these patients, the average collection across the agencies was $232.30, on an average patient charge of $1,538.41, representing a 15.1% collection rate.
•  Data recently provided by the Public Consulting Group (PCG) derived from Medicaid cost reports found that in 2021, the average provider cost for responding to a call and transporting a patient to a hospital was $2,351.34.
• • Therefore, for 13.3% of EMS responses, on average, the uncompensated care cost is $2,119.04 per patient ($2,351.34 - $232.30).
• According to a report from the National Association of State EMS Officials (NASEMSO), there were 15.9 million EMS patient transports in 2018.
• • Applying the uncompensated patient percentage of 13.3%, this means that 2,114,700 of these transports are provided at a loss of $2,119.04 per transport, for a total cost of uncompensated care of $4.5 billion.

Interesting perspective by a former insurance regulator. 

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Opinion: Ambulance importance

By BRENDAN WILLIAMS

06-04-2024

https://www.concordmonitor.com/My-Turn-Ambulance-bill-NH-state-house-55420534

Brendan Williams is the president and CEO of the New Hampshire Health Care Association.

It is a story often told: A bipartisan New Hampshire Senate bill, in this case co-sponsored by over half the Senate, passes the Senate and is eviscerated in the House.

This particular story involves Senate Bill 407, which addresses what insurers pay for ambulance services.

As it passed the Senate, it would require insurers to pay rates that are fair, as part of a genuine negotiation between an insurer and an ambulance company. In the absence of an agreement between the insurer and the provider, the Senate would require that the insurer pay rates set by the local government or contracted entity subject to a public process, or rates tied to what Medicare pays, or the billed charges, whichever is the least expensive amount.

Sound reasonable? It certainly would be great for Granite Staters who too often today can find that ambulance services are hard to access, particularly in rural areas, because of the costs of inflation, including wages.

A report issued last year by New Hampshire Ambulance Association surveyed 150 emergency medical service leaders, and 98% of them said the system was in urgent need of attention. One ambulance company alone had 50 job openings it couldn’t fill because reimbursement was not high enough to compete in the job market. Other companies were going out of business.

In contrast, health insurance companies seem to be doing okay. For example, even after nearly bringing down the U.S. healthcare system due to one of its myriad subsidiaries, which handles insurance billing, experiencing a cyberattack that could have been avoided with simple cybersecurity, UnitedHealth Group has a market cap of $455.93 billion as I write this. That’s thirty times bigger than the size of the state of New Hampshire’s current two-year budget.

As a former state insurance regulator, I can attest to the fact that for providers and patients alike to be chiseled by health insurers is as American as apple pie. I paid $9,100 out-of-pocket last year even though I was “insured” — an experience too many can relate to. Health insurers are even buying up medical practices so that they can steer those they insure to themselves, cleverly bypassing the already generous Affordable Care Act limits on how much they can pocket. One major New Hampshire insurer was reimbursing less for ambulance services than it did a decade ago. Why? Because it can get away with it.

As it passed the Senate, SB 407 would apply a very small leveling to this uneven playing field and benefit all Granite Staters who need an emergency response or transportation to a health care provider. The current crisis has, for example, burdened hospitals when an ambulance is not available to transport a patient ready for discharge into a long-term care setting. Yet in the House, this good bill got turned into a study.

It is a classic legislative move: When you don’t want to do something you just study it. I cannot count how many study committees I have been a part of that have completely failed to accomplish anything substantive. And then sometime later another study committee studies the same thing.

The Senate has refused to concur in the House approach and there is now a conference committee between the two legislative chambers.

The House should yield to the Senate position. Especially in a state as rural as ours, the well-being of Granite Staters, including some of our most vulnerable citizens, depends on having a viable ambulance sector.

Excellent news out of New York!

Nice to see another state begin the process to authorize Medicaid to pay for Treatment in Place (TIP) and Transport to Alternate Destinations (TAD), as well as designate EMS as an essential service.

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New York state Senate passes measures aimed to support emergency medical service providers

By Luke Parsnow New York State

May 29, 2024

https://spectrumlocalnews.com/nys/central-ny/politics/2024/05/29/n-y--state-senate-passes-bills-aimed-to-support-emergency-service-providers

The New York state Senate on Wednesday passed a legislative package aimed to expand resources for emergency service providers, Democratic leadership announced.

The legislation is made up of bills that would:

• authorize Medicaid reimbursements to emergency medical service agencies for providing emergency medical care to Medicaid enrollees without requiring the transportation of these patients from the place where medical care was administered. It would also permit Medicaid payments to be made to EMS services when they transport individuals to alternative care facilities instead of only hospitals. 
• permit more ambulance services and advanced life support first responders to store, administer and distribute blood. All ambulances, whether airborne or grounded, would qualify to transfuse blood products to patients to resuscitate them during transport.
• allow the state Department of Health to charge ambulance service providers a universal service assessment fee to cover increased medical assistant payment rates for their services.
• increase the volunteer firefighters’ and ambulance workers’ personal income tax credit from $200 to $800 for eligible individuals, and from $400 to $1,600 for eligible married joint filers.
• declare general ambulance services as an essential service, establish special districts for the financing and operation of generation ambulance services, and provide for a statewide comprehensive emergency medical system plan.

“Emergency medical service providers are the backbone of our healthcare system in times of crisis. This legislative package ensures they have the support and resources necessary to continue their life-saving work,” state Senate Majority Leader Andrea Stewart-Cousins said in a statement. “By addressing financial, operational, and systemic challenges, we are reaffirming our commitment to the health and safety of all New Yorkers.” 

State lawmakers are pushing their priorities before the legislative session ends on June 6.