News & Updates

In cooperation with the American Ambulance Association, we and others have created a running compilation of local and national news stories relating to EMS delivery. Since January, 2021, over 1,900 news reports have been chronicled, with 49% highlighting the EMS staffing crisis, and 34% highlighting the funding crisis. Combined reports of staffing and/or funding account for 83% of the media reports! 96 reports cite EMS system closures/agencies departing communities, and 95% of the news articles reference staffing challenges, funding issues and response times.

Click below for an up to date list of these news stories, with links to the source documents.

Read Only - Media Log as of 4-8-24.xlsx

  • 27 Jul 2023 8:47 AM | Matt Zavadsky (Administrator)

    These 2 articles are a nice primer on the Hospital @ Home model.

    They explain the model, and highlight the reasons for growth, potential challenges to growth, and the increasing role of EMTs and paramedics in the H@H model.

    Some innovative H@H agencies are partnering with transformative EMS agencies, including we here at MedStar, to deliver episodic and routine care using trusted, local providers.

    Imagine a day when an EMS response results in the EMS crew using telemedicine to ‘admit’ the patient to the hospital, at home, and the patient does not require transport to the hospital… 


    Why home is becoming the future for hospitals


    June 07, 2023

    More than 400 hospitals and hospital systems have hospital-at-home programs, despite uncertainty over what future reimbursements might look like under Medicare.

    Hospital-at-home has exploded since the COVID-19 pandemic and is expected to grow 50% over the next few years due to an increase in the number people over age 65, including 72 million baby boomers. Hospitals say treating patients at home can reduce healthcare costs and improve patients' emotional well-being as they recover with family and friends.

    Here is what you need to know about the growing hospital-at-home trend.

    What is hospital-at-home?

    Hospital-at-home allows patients who need acute care to receive treatment in their homes, rather than in a hospital. Providers use remote patient monitoring to keep an eye on patients' vital signs. They also rely on laptops or other mobile devices to communicate with patients and caregivers. Congestive heart failure, pneumonia and COVID-19 are a few of the illnesses often treated through the model. The program allows hospitals to free up beds for the sickest, more costly patients, while still providing care to other patients at home at a reduced cost to providers and the payers.

    Is it a new care model?

    Hospital-level treatment at home has been around since the 1970s in the United Kingdom, Canada and Israel. It came to the U.S. in 1995 when Johns Hopkins School of Medicine and Public Health in Baltimore piloted hospital-at-home. Johns Hopkins found the program reduced inpatient stays and lowered overall medical costs by a third. By 2002, Johns Hopkins, Presbyterian Health Services in Albuquerque, New Mexico, and a half dozen Veteran Administration medical centers began offering the care model.

    What impact did the COVID-19 pandemic have?

    The pandemic accelerated the care model's growth. In March 2020, the Centers for Medicare and Medicaid Services launched the Hospital Without Walls initiative to help hospitals overwhelmed with COVID-19 patients increase capacity. Eight months later, CMS expanded the program as Acute Hospital Care At Home, giving hospitals greater flexibility to treat patients at home and receive the same reimbursement rates as patients in hospitals. By the middle of 2021, nearly 170 hospitals and health systems in 29 states offered hospital-at-home. Today 406 hospitals and health systems in 33 states offer the program. Congress extended the reimbursements until the end of 2024.

    What are the requirements of hospital-at-home?

    CMS requires hospitals to carefully screen patients for medical and non-medical factors, such as suitability of the home. Patients are typically enrolled in the program from emergency departments or inpatient beds by a physician. They must be evaluated daily by a doctor or advanced practice nurse either in-person or virtually. Patients must also be evaluated remotely or in-person twice a day by a registered nurse or a paramedic. Hospitals must provide an on-demand connection to a nurse or physician at a command center who must be able to respond within 30 minutes if a patient's physical or mental health is deteriorating. Providers must also be able to connect patients to other necessary services, such as meals, pharmacy and laboratory tests.

    Who are the key players?

    Johns Hopkins, Rochester, Minnesota-based Mayo Clinic, Oakland, California-based Kaiser Permanente and Cleveland, Ohio-based Cleveland Clinic are among the largest hospital systems offering hospital-at-home. A handful of companies partner with hospitals to provide one-stop shopping to set up the programs. Those companies include Boston, Massachusetts-based Medically Home and Biofourmis, as well as Nashville, Tennessee-based Contessa Health, which is a unit of Amedisys. Those companies coordinate staffing, provide command centers, remote patient monitoring and offer a variety of other turnkey solutions.

    What is the market's growth potential?

    Healthcare research firm Chilmark forecast the hospital-at-home market would grow from approximately $200 billion in 2023 to $300 billion by 2028. Chilmark analyst Elena Iakoveva said technology and healthcare disrupters, including Amazon and Best Buy, could add hospital-at-home services to their healthcare offerings that include One Medical and Current Health, respectively.

    What might slow its growth?

    There are no guarantees Medicare and private health insurers will continue to reimburse hospitals at the same rate for patients receiving care at home versus the hospital. The concept also faces barriers in rural areas that often lack reliable internet service to connect patients to medical staff. And the nursing shortage could make it difficult for hospitals to deploy enough clinicians to make the necessary visits, especially to remote areas. While nurses in hospitals can care for several patients at one time, nurses deployed to homes may only care for four or five patients a day. Patient preference and safety are two other challenges. Many patients still would rather receive care in a hospital and others may not have in-home support from family caregivers to safely stay at home. Some family members who act as caregivers may also lack the skills necessary to help care for a very sick patient.


    Payment concerns not stopping new hospital-at-home programs


    July 27, 2023

    Hospital-at-home is attracting a new field of providers who say they can sustain the model despite uncertainty over how Medicare will reimburse for the service in the future. Home health agencies and even senior living companies are launching versions of hospital-at-home that don’t rely on reimbursement from Medicare fee-for-service.

    The CMS Acute Hospital at Home Waiver launched in November 2022, which allows hospitals and health systems to treat patients outside of their walls, is set to expire at the end of 2024. Medicare reimburses hospitals at the same rate for in-home care as it does for an in-facility stay. However, the waiver requires patients to visit an emergency department or be a patient in a hospital before being transferred to hospital-at-home.

    But other payers don’t have that requirement, making it easier for home health agencies and other providers to launch hospital-at-home programs without the threat that Medicare reimbursement might change.

    Senior health company Lifespark, which provides primary care, home health and hospice services, and owns 40 senior living facilities in Minnesota and Wisconsin, plans to launch a hospital-at-home program by year's end. The St. Louis Park, Minnesota-based company piloted a similar program in partnership with North Memorial Hospital in Minneapolis for about six weeks in 2020 during the COVID-19 pandemic.

    Lifespark takes on full risk for approximately 25,000 older adults through value-based care arrangements with Medicare Advantage plans. Founder and CEO Joel Theisen said the hospital-at-home program under development would target those patients and will likely include collaboration with hospitals.

    “We can intercept at the hospital and transition [them] early to acute-care-at-home, " Theisen said.

    Home health providers CenterWell, Elara Caring, Enhabit and Home Instead have forged partnerships in recent months with in-home healthcare provider DispatchHealth to provide hospital-level care to clients. The Denver-based company sends emergency medical technicians and nurse practitioners into the homes to evaluate patients under the virtual direction of a physician. Patients requiring hospital-level care can be enrolled in DispatchHealth’s acute-care-at-home program. The service is covered under many Medicare Advantage plans, managed Medicaid plans and private health plans.

    “We essentially receive a bundled payment for that episode and we provide all of the necessary care,” said DispatchHealth Founder and CEO Dr. Mark Prather.

    Healing Hands, a Dallas-based home health company, launched hospital-at-home in 2018 and gets reimbursed through the CMS' home health prospective payment system. Payments cover nursing care, telehealth, remote patient monitoring and home healthcare–all components of hospital-at-home.

    Healing Hands CEO Summer Napier said her company identifies those home health clients whose conditions are deteriorating and require acute-level care, and then works with primary care physicians to transition those patients to its hospital-at-home program. Napier said Healing Hands has provided hospital-at-home care to approximately 900 patients so far.

    The home health model could provide a possible guide to CMS as it considers the future of hospital-at-home reimbursement after the Medicare waiver expires. A study last year by healthcare consultancy Milliman said designing a Medicare reimbursement approach for hospital-at-home based on a home health payment, with additional payments for expanded services, could be less costly than a hospital-centered payment.

    A home health-based Medicare fee-for-service payment could encourage more home health providers to add hospital-at-home. But Dr. Robert Moskowitz, chief medical officer for hospital-at-home company Contessa Health, said it can be challenging for some home health agencies to scale hospital-at-home if they don’t have the appropriate technology or staff.

    “A lot of home health entities might be employing home health nurses, but they’re not used to that [higher] level of acuity,” Moskowitz said. “You’ve got to have the comfort level of competency for the nurse providing the care.”

  • 25 Jul 2023 5:15 PM | Matt Zavadsky (Administrator)

    I’ve had the honor of knowing and working with Chief Schaeffer for many years – he’s showing true leadership here, as usual, making data-driven decisions!

    Note the transition of some ALS units to BLS units, and the reduction of fire department responses to some non-life-threatening calls.

    Also note this accurate statement in his memo: “The lack of paramedics is not unique to SFD. In fact, the entire U.S. Fire Service is suffering the same challenges, and we are all trying to navigate this difficult reality.”

    This is not an issue with any one provider type - fire-based, 3rd service governmental, private, hospital-based – we are all facing the same reality.


    Spokane Fire Department announces changes to paramedic units, staffing

    Will Wixey

    Jul 18, 2023

    SPOKANE, Wash. -- Due to a severe shortage of paramedics, the Spokane Fire Department announced it's making changes to its system.

    The department says it's relocating some units for non-life-threatening emergencies.

    Spokane Fire Chief Brian Schaeffer says this change will widen the geography for paramedic units and shouldn't impact life-saving care.

    Schaeffer says the department will continue to evaluate outcomes as the changes are rolled out.

    Schaeffer says paramedics are currently working overtime too much, and it’s not sustainable, leading to burnout and major overtime costs.

    "We're redeploying our paramedics and they're covering a larger geographical area, and at the same time we're reducing the number of non-life-threatening calls that we're going to," said Spokane Fire Chief Brian Schaeffer.

    The department aims to implement these changes in mid-August.

  • 24 Jul 2023 11:07 AM | Matt Zavadsky (Administrator)

    Congratulations, Joel, and Three Rivers Ambulance Authority Team!!

    For perspective – note Indiana’s Medicaid rate increase mentioned in the Editorial; from $160 per ambulance run to $470; which is essentially Medicare Parity, something EMS agencies across the country have been advocating for. That is a significant increase, especially when national cost report data reveals that the average cost of putting an ambulance in front of an address was about $2,400 in 2021, and Medicaid patients represent 15%-30%.


    TRAA turnaround a win-win for all so far

    Editorial board | The Journal Gazette

    Jul 22, 2023

    Since Three Rivers Ambulance Authority fired PatientCare EMS Solutions last September due to its abysmal record in meeting performance goals, the quasi-governmental nonprofit has made rapid progress in improving service.

    In January, the ambulance authority met the 8½-minute response goal on calls for service 84% of the time. On Friday, TRAA reported meeting that mark during 89.5% of its ambulance runs, up from just 64% the previous year.

    “Ninety percent kind of is the magic number for us. And for us to be at that point this far into the month of July is actually incredible,” Joel Benz, executive director of the ambulance authority, told The Journal Gazette Friday.

    Another mark of the TRAA turnaround was announced in June at its board of directors meeting: Through managing expenses, an increase in federal reimbursements and a new billing system, the ambulance authority might not need to draw upon the city and county funds it requested earlier in the year.

    The city of Fort Wayne pledged up to $3 million to TRAA in March, and the ambulance authority has discussed financial assistance with the Allen County Commissioners. In May, Benz reported the Fort Wayne City Council allowed TRAA to retain $400,000 it usually pays the city for advanced life-support training each year.

    The ambulance authority has used the $400,000, but hasn’t requested any of the $3 million.

    TRAA Finance Manager Carrie Henry told board members at their June 22 meeting the ambulance authority is operating at a loss of $213,131 for the year – a vast improvement over the $1.5 million the nonprofit had anticipated.

    The deficit reduction was achieved through better management of expenses and hiring a new billing company, Med-Bill, in September – the latter having the greatest impact on the bottom line, Benz said.

    Before hiring Med-Bill, TRAA was collecting between $550,000 and $600,000 each month. Med-Bill brought in $1.1 million in May alone.

    Reimbursements from Medicaid will increase from $160 per ambulance run to $470 this month, while Medicare reimbursements will go up 8%, Benz said at the June meeting. Medicaid patients accounted for about a third of TRAA’s runs last year, and Medicare patients made up another 43%.

    Those reimbursement increases will positively impact the ambulance authority’s revenue. But Allen County’s launch of fire districts in the northeast and southwest this January could adversely affect TRAA revenue in 2024.

    The northeast fire district will include the current fire territory’s municipalities of Grabill and Leo-Cedarville, and Cedar Creek, Milan, Scipio and Springfield townships. A fire district southwest will cover unincorporated Lafayette, Pleasant and Wayne townships and Zanesville.

    TRAA has 61 full-time ambulance employees. Full staff for the ambulance authority is 82 full-time employees, Mike Manz, director of operations, told the TRAA board. Its starting wage for a paramedic is about $56,000 a year. Benz said the county is looking at paying paramedics $73,000 annually.

    “I think we made significant progress, but part of the story is we are still underpaid here compared to county services,” Benz said. “I’ve got a half-dozen paramedics that are looking at moving to the county, probably more than that.”

    TRAA’s transition to run medics and ambulance services has brought down response times and reduced costs. That decision has been a win for its employees, city residents, and county fire departments and residents.

    There remain significant challenges for TRAA, especially regarding a shortage of trained paramedics and the inevitable resulting wage competition. But just 10 months into TRAA’s takeover of the ambulance authority, there has been dramatic improvement in the all-important response times, which undoubtedly improve patient outcomes, costs are down and revenue is up.

    There are too many variables in the mix for 2024 to know whether this progress can continue without additional help from the city or county, but it has been a win-win for all so far.

  • 20 Jul 2023 7:49 AM | Matt Zavadsky (Administrator)

    Great summary of the myriad policy issues – and rational approach to EMS system redesign!  Many systems are taking this evidence-based approach to enhance patient, provider and public safety. At Medstar, our reprioritization plan, implemented on March 1, 2023, dropped HOT responses from 73% of our responses, to 37%!

    Tip of the hat to Kolby Miller for sharing this news report!


    Your wait for an ambulance may get longer — and that's safer

    By Dustin Walsh

    July 17, 2023

    Ambulance service is built on response time — the ability to get to a suffering patient and to the hospital swiftly to save blood loss, an appendage, or a life. The public has come to not only expect but demand the quickest response possible because, frankly, emergencies are frightening.

    But, in reality, only about 5% of patients transported by ambulance actually benefit from "hot" rides, where the ambulance's lights and sirens are ablaze, growing research suggests, including a study by the World Association for Disaster and Emergency Medicine. Yet three-quarters of all 911 transports in the U.S. run hot, while the chance of a crash with a patient onboard rises three-fold.

    "Racing around all the time, we're going to kill somebody on the way to a call for somebody that didn't even need an ambulance anyway," said Kolby Miller, CEO of Clinton Township-based MedStar, the state's largest emergency medical services organization jointly owned by Ascension Health, Henry Ford Health System and McLaren.

    But MedStar ambulances run hot anyway because their services are contracted by municipalities almost exclusively for one performance metric — response time. In fact, 70 percent of its roughly 100,000 ambulance requests annually involve an ambulance running lights and sirens.

    Miller wants to change that and is part of an informal nationwide effort to educate municipalities and medical control authorities that contract emergency medical services on the dangers of lights and sirens and what little factor they play in aiding patients.

    "You think you want an ambulance to get you to the hospital at 100 mph, but at 100 mph that vehicle travels 450 yards before it can stop. We bring risks and accidents into the system while chasing a false metric," Miller said. "Response time just doesn't have the impact on patient outcome we want to believe it does and we're jeopardizing everyone's safety."

    Little need for speed

    The focus of ambulance response times dates back 50 years to the Emergency Medical Systems Service Act of 1973, which stated that 95% of all ambulance response time should be within 10 minutes in urban areas and 20 minutes in rural areas.

    But municipalities and medical control authorities began demanding quicker responses in the late 70s as research indicated intervention within 6 minutes of cardiac arrest substantially increased survivability.

    That's led to quicker and quicker response times, no matter the injury or emergency.

    Today, the national standard for EMS performance agreements is 8 minutes and 59 seconds, meaning a response must be under 9 minutes. Due to competition and expectations, that means most emergency calls receive an ambulance within 4 to 6 minutes, Miller said. The national average response time is seven minutes.

    Nationally, about 72 percent of 911 calls requesting an ambulance receive one with lights and sirens, and 21 percent of those ambulances transport the patient with lights and sirens on.

    It's not just the average response time, however, that leads to ambulances traveling at high rates of speed and splitting traffic when they can.

    Many emergency dispatch operations are run by municipalities or counties and do not require someone with medical training. So because response time is critical with cardiac arrest and a small percentage of other emergencies, ambulance services have no choice but to travel quickly, said Angela Madden, executive director of the Michigan Association of Ambulance Services.

    "Many (dispatchers) don't have medical training, so they cannot clearly work through the patient's symptoms," Madden said. "Without that understanding of the patient's issue, ambulances have to go to the scene with lights and sirens."

    Miller said about 30 percent of the time a MedStar ambulance — which serves patients in Bay, Clinton, Eaton, Genesee, Ingham, Lapeer, Macomb, Oakland and Wayne counties —arrives at the scene, a patient doesn't even require an ambulance transport to the hospital.

    However, when the EMS provides the dispatch service, there's a noticeable change.

    Grand Rapids-based Life EMS Ambulance, which has a 4,600-square-mile service area from Kalamazoo to West Michigan and has certified medical emergency dispatchers in most of its communities, only sends an ambulance with lights and sirens on 36% of its more than 100,000 transports, said Mark Meijer, president and founder.

    "We've been fortunate to have some forward-thinking medical directors and medical control systems overseeing our clinical care," Meijer said. "That's really helped drive down our use of lights and sirens and helped us ascertain what calls require them or not."

    Miller said he's worked hard to educate decision-makers about reducing lights and sirens use by setting up informational meetings, but "hardly anyone shows up."

    Adjusting services for need

    There is evidence to support these efforts.

    Mecklenburg County EMS Agency, which provides services to the county in North Carolina that includes Charlotte, recently changed its response protocols after an in-depth study of the way its dispatch operated.

    The county discovered that 74% of its 911 ambulance requests were dispatched as life-threatening and required the use of lights and sirens. However, after arriving at the scenes and accessing the scenarios, only five percent were determined to actually be life-threatening and require lights and sirens.

    Being able to distinguish between the two aids in resource distribution. Paramedics ride in advanced care ambulances, which are equipped with life support equipment. Non-life-threatening calls receive basic life support (BLS) ambulances, which have medical equipment but lack the advanced equipment of an ALS ambulance.

    Since October 2021, for calls that are determined to be non-emergency calls, Mecklenburg EMS set a target of a 60-minute or less response time. After 12 months, Mecklenburg EMS reported an average response time of 32 minutes with zero patients adversely impacted.

    In March, Mecklenburg EMS extended its non-emergency response time to 90 minutes or less.

    "If a dispatcher says chest pain, the ambulances are coming as fast as they can," Madden said. "But the more information the dispatcher can receive and be trained to understand, then they can send an appropriate response."

    Life EMS Ambulance also outperforms the national and state averages despite a lower use of lights and sirens. The survival rate of a total cardiac arrest patient after EMS response is roughly 30% nationally and 25% in Michigan, Meijer said. For Life EMS, it's 37%.

    Miller and Meijer both said that performance metrics need to change with the times, where more paramedics are employed and AEDs and CPR training is prevalent.

    "It's clearly a challenge that one longstanding measurement of how an EMS performs is response times," Meijer said.

    "We need to figure out how we can better inject quality measures from a clinical care and outcome standpoint, using those measures predominantly or at least more so than simple response times. That's still a work in progress."

  • 20 Jul 2023 7:48 AM | Matt Zavadsky (Administrator)

    The inability of some states to put a price tag on an essential service designation is a common pushback in many states. The patchwork of reimbursement and funding streams adds to the conundrum!


    Amid funding concerns, lawmakers reject push for EMS as essential service

    Aedan Hannon

    Jul 5, 2023

    Lawmakers on a legislative health panel declined last week to move forward with a draft bill that would have made emergency medical services (EMS) an essential service in Wyoming and seen the state contribute directly to ambulance care for the first time.

    The failed proposal to establish a state-backed grant program for EMS providers comes as first responders and the state wrestle with the sustainability of Wyoming’s fragile and precipitous ambulance infrastructure, a problem rooted in unstable funding and a declining workforce that those involved say has no clear or immediate solutions.

    Members of the Joint Labor, Health and Social Services Committee split over the proposal to make EMS an essential service during last week’s interim meeting in Evanston. Their vote ensured that the committee will not sponsor the draft bill during the 2024 legislative session and likely signifies that EMS will not garner the status in the near future.

    Under the draft bill, local governments across Wyoming would have been required to provide ambulance services for the first time. Unlike firefighting and law enforcement, which are designated “essential services,” EMS is not, meaning that counties and cities don’t have to pay for ambulance services or ensure that their residents have access to them.

    With the added requirement, the proposal would have created a state-funded grant program administered by the Wyoming Department of Health to cover the EMS costs that local governments could not afford, guaranteeing the survival and operation of ambulance providers across the state.

    During the health committee’s first interim meeting in April, lawmakers voted by a slim 7-6 margin to draft an EMS essential service bill. The panel heard from EMS providers and the Wyoming Hospital Association who testified that state funding and labeling ambulance care an essential service would help to address some of the financial challenges making EMS increasingly difficult to sustain.

    The second time around lawmakers on the health committee were again skeptical. They questioned the financial consequences of an EMS requirement, as well the role of the state in what some argued is a local issue.

    “In order to move this bill forward we would need to know what the fiscal impact would be,” said Rep. Ben Hornok, R-Cheyenne. “And we don’t have that.”

    Hornok, Rep. Jeanette Ward, R-Casper, and Sens. Anthony Bouchard, R-Cheyenne, and Lynn Hutchings, R-Cheyenne, pointed to the money that the state has previously funneled into EMS. A memo from the Legislative Service Office highlighted the state’s “EMS Sustainability Trust,” which was created in 2009 with $500,000 from the state’s Tobacco Settlement Trust Fund to pay for needs assessments for EMS providers. The state has also invested another $15 million in federal pandemic funds toward stabilizing EMS agencies and “regionalization pilots” to improve ambulance services across Wyoming.

    “I think it’s important that we’re provided information about … where’s that money gone so that we can make an informed decision,” Hutchings said.

    Wyoming has a patchwork of EMS services. Some agencies are private, others are run by hospitals, counties or rural health districts, making it difficult to pin down exactly how much the state would need to contribute, Jen Davis, the health and human services adviser for Gov. Mark Gordon, told lawmakers.

    The state’s EMS agencies currently depend on local revenue and insurance reimbursement, but part of the problem is that ambulances are typically only reimbursed for transporting patients to hospitals or other health care facilities, EMS and health care officials testified in April. According to the Wyoming Department of Health, roughly 35% of all EMS calls are uncompensated in the state, leaving ambulance agencies and local governments on the hook to make up for those costs.

    Some of those on the committee expressed concern that adding state funding wouldn’t fix the reimbursement issues plaguing the industry, which stem in part from federal Medicaid and Medicare rules that categorize EMS agencies as transportation rather than health care providers. But those who testified urged lawmakers to address a worsening situation for ambulance agencies.

    “Medicare is a key component to this, but it’s also a place where we don’t have control either,” Davis said. “We still have an issue that we have to solve.”

    Amid the hesitation, Sen. Fred Baldwin, R-Kemmerer, a co-chair of the committee, cautioned lawmakers about the potential consequences of inaction after Hornok advocated for the committee to see what impact a new bill allowing county boards to form EMS districts would have before taking action.

    “If we wait until we see whether that works or not, we may well lose some EMS districts,” Baldwin said.

    Davis told lawmakers that she knew of some communities who were considering creating EMS districts, which would require a local vote to raise property taxes to fund the new districts. Others have told the Governor’s office that would not be able to finance them, she said.

    As the committee wavered, Davis acknowledged that there are no easy solutions to Wyoming’s EMS challenges. But, she said: “We have to do something.”

  • 27 Jun 2023 10:14 AM | Matt Zavadsky (Administrator)

    Start-up costs of Brattleboro EMS takeover, sold as a money saver, could total $1.9 million

    Municipal leaders have revised estimates to launch a town-run ambulance system after dropping a nearly six-decade contract with the private nonprofit Rescue Inc., which most recently charged $285,600 a year.

    By Kevin O'Connor

    June 21, 2023

    BRATTLEBORO — Start-up costs for a proposed fire department takeover of local emergency medical services could cost taxpayers nearly seven times as much in the first year than the annual charge of this town’s former EMS provider, Rescue Inc., municipal leaders said Tuesday.

    The Brattleboro Selectboard surprised residents in April 2022 when it voted with little notice or public debate to drop its nearly 60-year contract with Rescue, a private nonprofit, as part of a transition plan to study whether the town should pick up ambulance coverage.

    Then-Town Manager Octavian “Yoshi” Manale claimed the plan not only would cost less than Rescue’s $285,600 annual fee but also reap a “$500,000 to $700,000 net gain in revenue.”

    But that original outlook by Manale — who abruptly resigned eight weeks later — hasn’t proved true in a test run with Golden Cross Ambulance of Claremont, New Hampshire. And a full takeover by the town in 2024 would require start-up costs of between $1.3 million and $1.9 million, municipal leaders told the selectboard Tuesday night.

    The revised estimates are nearly eight times more than the start-up figures Manale presented at an April 2022 selectboard meeting during which members voted unanimously to drop the Rescue contract.

    In an April 2022 memo, Manale said the town could purchase one “refurbished” ambulance for $110,000, a second “used” ambulance for $55,000, paramedic school enrollment for $36,000, related equipment for $30,000, radios for $15,000 and vehicle lettering for $3,500 — all for a total of $249,500.

    “Most start-up costs will come from savings for the town in the new contract,” wrote Manale, projecting his plan would spend less than Rescue, the region’s largest and longest-serving EMS provider.

    Instead, the town has spent more on EMS since the change, having drained the last dollars of a projected surplus just weeks after the July 2022 switch, its spending shows.

    On Tuesday, municipal leaders presented new start-up estimates that said the fire department would have to hire an EMS supervisor (at $127,056 a year) and six new firefighters (at $88,404 each). Their salaries would total $240,000 during the launch period before becoming an annual projected $657,480 operating expense.

    The plan also calls for a $20,000 transition consultant, a $30,000 billing software program and a $250,000 fund to make up for the lag between charging and collecting ambulance fees from insurers.

    The fire department would also have to buy three ambulances, with new models currently priced between $200,000 and $400,000 each.

    Depending on the vehicles, local leaders estimate start-up spending would total $1.3 million to $1.9 million, which they said could be covered by federal American Rescue Plan Act money or by borrowing funds through bonding.

    Residents at Tuesday’s meeting expressed reservations.

    “I’m really concerned about the financial impact on the taxpayers of Brattleboro,” said Dick DeGray, a former selectboard member who tends downtown’s flower planters.

    Leaders haven’t shared any of the facts or figures that prompted them to approve the change, nor have they yet outlined annual operating expenses past the first year. But an independent feasibility study found that a municipal takeover would increase costs, yet bolster the town’s understaffed system of crisis response.

    Specifically, the study said the town could collect an estimated $935,626 in annual insurance payments if it funded enough employees and equipment to respond to all EMS calls, but still would need to pay more than $300,000 a year to cover $1.2 million in expenses — a figure higher than the most recent Rescue contract.

    Tuesday’s meeting was the latest in a monthly series launched after this year’s March Town Meeting adopted nonbinding resolutions calling for a “transparent” decision-making process for both ambulance coverage and related ARPA spending.

    In response, the municipal government is using the selectboard’s regular meetings to present EMS information and invite public comment. Local leaders are set to discuss operating models on July 25, review all information on Aug. 15 and invite more community input on Sept. 5 and Sept. 12 before voting on an option Sept. 19.

  • 26 Jun 2023 12:35 PM | Matt Zavadsky (Administrator)

    This is NOT just a rural EMS issue – EMS systems across the country are in the midst of a financial and staffing crisis, urban and rural. 

    In a rolling tally of local and national media reports since January 2021, of 1,053 local and national media report about EMS, 347 reports are about the funding crisis, and 623 are about the staffing crisis. EMS leaders know the 2 issues are linked.  This means 92% of media reports are about funding and staffing challenges for EMS systems.


    What if the ambulance doesn't come? Rural America faces a broken emergency medical system

    Nada Hassanein


    June 26, 2023

    Melissa Peddie, EMS director and paramedic, drives the single ambulance that serves Liberty County in rural north Florida.

    During any shift, there are just two full-time paramedics driving the lone truck around the 1,176-square-mile sparsely populated county.

    Just a couple of weeks ago, Peddie and her husband, the local fire chief, drove their own car to stabilize an older man who fell and was unable to get up – the ambulance was on another call. The couple waited with the patient and his family until an ambulance from a county 30 minutes away could come to take him an hour east to Tallahassee, the state capital and home to the nearest trauma center hospital.

    “We've done that quite often,” she said. “Jump in my car and go to the scene and stabilize, maintain until a crew or somebody can get there.”

    Often, she must call two or three neighboring counties to find an ambulance for mutual aid.

    Nearly 4.5 million people across the U.S. live in an "ambulance desert" – 25 minutes or more from an ambulance station – and more than half of those are residents of rural counties, according to a new national study by the Maine Rural Health Research Center and the Rural Health Research Centers.

    As rural hospitals shutter across the nation, dwindling emergency medical services also must travel far to the nearest hospital or trauma center. Experts and those in the field say EMS needs a more systematic funding model to support rural and poorer urban communities.

    “This is a really extreme problem, and we need to figure out solutions. People think that when you call 911, that someone's coming in,” said lead author Yvonne Jonk, deputy director of the Maine Rural Health Research Center. “Most people don't realize that their communities don't actually have adequate coverage.”

    'In crisis mode'

    About 15% of the U.S. population lives in rural areas like Peddie’s Liberty County, where poverty and mortality rates are higher than in urban areas.

    Four of 5 counties across the nation have at least one ambulance desert, according to Jonk’s analysis of 41 states and data from 2021 and 2022.

    Some regions are more underserved than others: States in the South and the West have the most rural residents living in ambulance deserts.

    Eight states − Nevada, Wyoming, Montana, Utah, New Mexico, Idaho, South Dakota and North Dakota − have fewer than three ambulances covering every 1,000 square miles of land area.

    In North Dakota, more than 31,000 people, about 4% of the total state population, live in ambulance deserts, according to the analysis.

    PJ Ringdahl, regional adviser for the North Dakota EMS Association and paramedic, advocates for EMS stations across the state and holds listening sessions with other paramedic and emergency medical technicians.

    “We're all in crisis mode. We're all short-staffed. And we really have to try to figure out an appropriate model to be able to deliver health care to those communities,” Ringdahl said.

    Throughout the West, many of those communities are underserved American Indian reservations.

    In 2015, a Colorado-based emergency medicine physician and his wife used their retirement money to fund two ambulance stations in a North Dakota ambulance desert, the Fort Berthold Indian Reservation, where trucks would have to rush to emergencies from at least a half-hour away.

    Meanwhile, the Fort McDermitt Paiute-Shoshone Tribe awaits help. The reservation stretches along the Nevada-Oregon border near Idaho and has no ambulance or hospital. Nevada has just 55 ambulance stations across the state, according to the analysis, and about 33% of the ambulance desert population is in rural areas.

    Tribal chairwoman Maxine Redstar said the community used to have an ambulance service, but it couldn’t afford to keep it going.

    “When you call an ambulance, it comes from Winnemucca," she said, "which is an hour away."

    Weather, wildlife and long, dark winding gravel roads make getting to the scene difficult.

    That's the case on the Duckwater Shoshone Tribe Reservation in the central Nevada desert valley, which doesn't have an ambulance, and the nearest one is an hour away. Tribal members take matters into their own hands. Janey Blackeye Bryan, 60, started first aid training as a teenager and became certified in community emergency response, then volunteered as an advanced EMT for years. Her daughter and son-in-law are volunteer EMTs, and her husband is a volunteer firefighter.

    "We've got medical issues here. You got to move somebody, you got to get them someplace really quick," Bryan said. But

    "we're located about 75 miles away from an emergency room. ... There is no golden hour."

    Inconsistent funding models jeopardize lifesaving services

    Few states designate EMS as essential services. In the U.S., EMS are mainly funded by local governments, and not all states allocate supplemental funds toward the services. In communities like Peddie’s, for example, the county’s general revenue budget must pay the bill, because supplemental state funding falls short. In addition, an EMS agency typically doesn’t receive reimbursements by insurance companies unless a patient is taken to an emergency room.

    “There's no systematic way to go about funding,” Jonk said. “It varies state to state as to how much funding they have at their disposal to throw at ambulance services.”

    Amid patchwork funding, communities rely on varied revenue sources to fund ambulance services, said Lindsey Narloch, project manager at Rural EMS Counts, a North Dakota EMS improvement project. That often doesn’t cover expensive equipment, medication and staff salaries. Counties end up having to pay most of the cost.

    “It's kind of a hodgepodge of a little reimbursements, some tax funds, some grants, volunteer labor,” she said.

    Poorer communities end up taking the brunt. High-income areas with larger proportions of white patients had shorter response times compared to poorer areas, according to one study of cardiac arrest emergencies and ambulance response.

    Unpaid volunteers often fill gaps. But that workforce is under threat as volunteers age and recruitment for new volunteers becomes more difficult.

    Recently, Gary Wingrove, president of The Paramedic Foundation, a Minnesota-based nonprofit, gave a presentation to policymakers and shared the story of a Wyoming-based volunteer EMT who drives to a community 300 miles away to fill in as a paramedic for one week a month.

    “One major problem we have is the payment system does not support full-time ambulance personnel,” Wingrove told USA TODAY. Funding needs to be sustainable and prevent volunteers from "having to drive 300 miles to do a full-time job and instead get paid" to serve their local communities.

    Critical access hospitals, which are medical centers in rural, underserved communities often with a high number of uninsured residents, are paid more than other hospitals if their care delivery cost is higher than the standard Medicare payment, he said.

    Amid rural hospital closures and reliance on volunteerism, “we need something similar for rural ambulance services,” he said. “We have to take a hard look at our financing of rural ambulance services. And to me, it just makes a lot of sense if we create a system like the critical access hospitals have for the rural ambulance services."

    ‘Forgotten about’

    EMS professionals are first responders but also health care providers, Ringdahl said, adding she wishes to see the service more supported within the U.S. health care delivery system.

    “The EMS profession needs a home,” she said. “EMS kind of sits on two sides. … So, when you don't have a home, sometimes you just get left behind. On a federal level, I'd like to see some initiative to maybe get us a little bit more rooted into that health care system.”

    On top of delivering critical health services, in rural areas EMS workers often must navigate rough terrain.

    “For a long time, we've done this on the backs of volunteers,” Narloch said. “There has to be a recognition that this is something that has to be paid for, and you have to pay people well to do. It's a big job.”

    Working a call recently, Peddie was in an accident that totaled her ambulance. The county now uses an older backup truck that Peddie fears will break down. A new vehicle would set the county back up to $300,000, she estimated. Manufacturers estimate a single vehicle can cost anywhere from $120,000 to $325,000.

    “We’re already in a major deficit,” she said. “You hope that your equipment stays intact and works.”

    Peddie said her profession is overlooked as a critical service.

    “We're forgotten about,” she said. “The moment someone needs us, they think about us. But after that, it's just a fading thought.”

    Reach Nada Hassanein at or on Twitter @nhassanein.

  • 18 May 2023 7:33 AM | Matt Zavadsky (Administrator)

    Reading this article and report, it reminded me of a question consumer advocates often raise when discussing the need for insurers to pay reasonable reimbursements for ambulance service (as it was during the recent 2-day HHS GAPBAC meeting) – if insurers have to pay ambulance services more, will they raise premiums?

    Yes, the pandemic reduced medical loss ratios for insurers, an increased the rebates, but looking at the historic charts, insurers have been issuing rebates for nearly a decade, meaning they are paying less than 80% of their premium $ on direct healthcare services.

    This, combined with the finding that ambulance service is approximately 0.3% of the healthcare spend, means that increasing ambulance reimbursement to a reasonable, usual, and customary fee, will likely NOT be a driving factor in premium increases.


    Insurers to give back more than $1B in rebates

    Tina Reed

    May 18, 2023

    Insurers will have to rebate about $1.1 billion to enrollees this year for not spending enough of their premium revenues on medical claims under the Affordable Care Act, a KFF analysis shows, Axios' Arielle Dreher writes.

    Why it matters: Since rebates are based on a three-year average of insurers' experience, the givebacks reflects the pandemic experience, when patients canceled elective procedures and generally used less care.

    • The ACA requires insurers in specified markets to spend at least 80% of premium income on health care claims and quality improvement, leaving the remainder for administration and overhead. Carriers that don't hit the threshold have to pay back the difference.

    In 2022, the average rebate in the individual market per person was $205, per KFF, while the average rebate for the small- and large-group markets was $169 and $110, respectively.


    2023 Medical Loss Ratio Rebates

    Jared Ortaliza, Krutika Amin

    May 17, 2023

    The Medical Loss Ratio (MLR) provision of the Affordable Care Act (ACA) limits the amount of premium income that insurers can keep for administration, marketing, and profits. Insurers that fail to meet the applicable MLR threshold are required to pay back excess profits or margins in the form of rebates to their enrollees.

    In the individual and small group markets, insurers must spend at least 80% of their premium income on health care claims and quality improvement efforts, leaving the remaining 20% for administration, marketing expenses, and profit. The MLR threshold is higher for large group insurers, which must spend at least 85% of their premium income on health care claims and quality improvement efforts. MLR rebates are based on a 3-year average, meaning that rebates issued in 2023 will be calculated using insurers’ financial data in 2020, 2021, and 2022 and will go to people and businesses who bought health coverage in 2022.

    We find that insurers estimate they will issue a total of about $1.1 billion in MLR rebates across all commercial markets in 2023, using preliminary data reported by insurers to state regulators and compiled by Mark Farrah Associates. Final rebate data will be available later this year. Some insurers have not yet filed their 2023 rebate estimates.

    Estimated total rebates across all commercial markets in 2023 ($1.1 billion) are similar to total rebates issued in 2022 ($1.0 billion). In 2022, rebates were issued to 2.4 million people with individual coverage and 3.8 million people with employer coverage, though rebates may be shared between employers and employees. In the individual market, the 2022 average rebate per person was $205, while the average rebates per person for the small group market and the large group market were $169 and $110, respectively (though enrollees could receive only a portion of this as rebates may be shared between the employer and employee or be used to offset premiums for the following year).

    The estimated $1.1 billion in rebates to be issued later this year will be larger than those issued in most prior years, but fall far short of recent record-high rebate totals of $2.5 billion issued in 2020 and $2.0 billion issued in 2021, which coincided with the onset of the pandemic.

    In 2022, the average individual market simple loss ratio (meaning that there’s no adjustment for quality improvement expenses or taxes and therefore, don’t align perfectly with ACA MLR thresholds) was 86%, meaning these insurers spent an average of 86% of their premium income in the form of health claims in 2022. However, rebates issued in 2023 are based on a 3-year average of insurers’ experience in 2020-2022. Some insurers experiencing relatively high loss ratios in 2022 nonetheless expect to owe rebates this year because those rebates also reflect their more profitable experience in the 2020 plan year.

    The effects of the pandemic continue to be felt, as rebates this year include experience from 2020 and 2021. In 2020, there were several factors driving health spending and utilization down. Hospitals and providers cancelled elective care early in the pandemic and during spikes in COVID-19 cases in order to free up hospital capacity, preserve supplies, and mitigate the spread of the virus. Many consumers also chose to forego routine care in 2020 due to social distancing requirements or similar concerns. As insurers had already set their 2020 premiums ahead of the pandemic, many turned out to be over-priced relative to the amount of care their enrollees were using. Some insurers offered premium holidays and many temporarily waived certain out-of-pocket costs, which had a downward effect on their rebates.

    In the small and large group markets, 2022 average simple loss ratios were 83% and 88%, respectively. Only fully-insured group plans are subject to the ACA MLR rule; about two thirds of covered workers are in self-funded plans, to which the MLR threshold does not apply.

    Rebate Payment Logistics

    The 2023 rebate amounts in this analysis are still preliminary. Rebates or rebate notices are mailed out by the end of September and the federal government will post a summary of the total amount owed by each issuer in each state later in the year.

    Insurers in the individual market may either issue rebates in the form of a check or premium credit. For people with employer coverage, the rebate may be shared between the employer and the employee depending on the way in which the employer and employee share premium costs.

    If the amount of the rebate is exceptionally small (less than $5 for individual rebates and less than $20 for group rebates), insurers are not required to process the rebate, as it may not warrant the administrative burden required to do so.

    What to Expect in Coming Years?

    Another year of higher loss ratios in the individual market may foretell further premium increases in 2024, as some insurers will aim for lower loss ratios to regain higher margins. In recent years, insurers in all markets had experienced a great deal of uncertainty in setting premiums during the pandemic. Looking ahead to 2024, some of that uncertainty may continue, specifically relating to pent-up demand or the health effects of missed and delayed care. Additional uncertainty in premium setting may come from the Medicaid continuous coverage unwinding, as millions of people are expected to lose Medicaid coverage in the coming months and may transition to other sources of insurance. Increases in provider wages and other costs due to inflation could lead to higher premiums. In the 2023 rate filings, Marketplace insurer actuaries cited increase in prices and utilization as drivers of the premium increases.


    We analyzed insurer-reported financial data from Health Coverage Portal TM, a market database maintained by Mark Farrah Associates, which includes information from the National Association of Insurance Commissioners. The Supplemental Health Care Exhibit dataset analyzed in this report does not include data from California HMOs regulated by California’s Department of Managed Health Care. All individual market figures in this data note are for major medical insurance plans sold both on and off exchange. Simple loss ratios are calculated as the ratio of the sum of total incurred claims to the sum of health premiums earned.

    Rebates for 2023 are based on preliminary estimates from insurers. Total rebates issued in 2022 differed by about 1% from estimated rebates. In some years, final rebates are higher than expected and in other years, final rebates are lower.

  • 15 May 2023 7:16 AM | Matt Zavadsky (Administrator)

    Another example of the impact of struggling EMS systems across our country…

    Tip of the hat to Dr. Jim Augustine for finding this news story!


    Report Finds New Hampshire EMS System in ‘State of Emergency'

    Of the 150 EMS leaders surveyed in the report, 98% of them said the system is in urgent need of attention. More than 90% said the health and safety of residents is being impacted as a result

    By Abbey Niezgoda

    May 11, 2023

    A new report says the EMS system in New Hampshire is in a state of emergency. From first responders leaving the field to ambulance companies shutting down, health officials said the situation is dire due to a number of factors including recruitment and reimbursement. 

    The report that was released this week by the New Hampshire Ambulance Association paints the picture. Of the 150 EMS leaders surveyed in the report, 98% of them said the system is in urgent need of attention. More than 90% said the health and safety of residents is being impacted as a result.

    “If we don’t address this, I truly believe folks in New Hampshire are going to die as a result of this crisis,” Justin Van Etten, the executive director of the New Hampshire Ambulance Association said.

    Van Etten said one of the biggest challenges is staffing. Right now Stewart’s Ambulance Service in New Hampshire has roughly 50 openings, but officials said the salaries make it hard to recruit.

    “A basic EMT is making on average $15 an hour to save your life,” Van Etten said.

    In order to raise salaries, ambulance companies are calling for Medicaid, Medicare and private insurance companies to increase what they reimburse for the services.

    State Sen. Sue Prentis (D-Lebanon) who has been a paramedic for nearly three decades is pushing a bill that would do just that.

    “My biggest fear is if somebody calls 911 right now, there won’t be anybody there to answer,” Prentis said.

    Health officials said right now 911 calls are not being impacted nearly as much as calls for patients who need to be transported from one hospital to another for care. In rural New Hampshire, they get these calls a lot.

    “People used to wait a few hours for ambulances to come get them at a facility. Now sometimes they are waiting days,” Van Etten said.

    Van Etten said this results in patients taking up beds in emergency departments for longer periods of time, which can make the wait time longer for everyone else waiting to be seen.

    Adding to the list of challenges, three private ambulance companies in New Hampshire have closed since January. It leaves other companies left to pick up the slack.

    “We try as best we can to provide coverage to them, but sometimes it’s just not possible,” Chris Stawasz of American Medical Response said.

    Stawasz said a new class of EMTs that just graduated thanks to the state’s “Earn While You Learn” program helps, but with more than two dozen open positions, it is not nearly enough.

    “By no means will this fill the entire void that we have, but it’s a great start,” Stawasz said.  

  • 11 May 2023 11:46 AM | Matt Zavadsky (Administrator)

    Great explanation of the root cause for the current state of ER issues, and recommendation for a fix…

    We also need to empower paramedics to care for patients in their homes under the direction of an emergency physician and not transport everyone to the hospital. This would become commonplace if insurance companies were willing to pay emergency medical services the same amount to care for a patient in their home as they do when the patient is transported to the hospital. It would also result in significant cost savings by reducing emergency department visits while taking pressure off already overwhelmed emergency departments across the state.

    Imagine that…


    Emergency rooms across the state are overwhelmed — there’s a proven fix

    What worked in a pre-COVID world does not work in the present day. However, what worked during the first surge of COVID could help.

    By Eric Dickson

    May 10, 2023

    Three years ago, emergency departments across Massachusetts were inundated with patients infected with COVID-19. In my 30-plus years of working in emergency medicine, I had never seen anything like it. No one had. We cared for patients in tents outside the emergency department. We set up hospitals in convention centers and we all worked together to care for our communities when they needed us most.

    What is hard to fathom is that some of the state’s emergency departments are in worse shape today than at the peak of the March/April 2020 COVID-19 surge, despite low rates of influenza and COVID-19. This is especially true at tertiary referral centers (facilities that provide highly specialized care for the sickest patients — also known as trauma centers) like Massachusetts General Hospital, Baystate Medical Center, and UMass Memorial Medical Center.

    In the trauma center I oversee, UMass Memorial Medical Center, it is not uncommon to have 80 patients boarding in the emergency department waiting for an inpatient bed. This limits our ability to see new patients and accept transfers from smaller community hospitals that have fewer capabilities. For patients with time sensitive, life-threatening illnesses, the inability to get to a tertiary referral center can be the difference between life and death.

    There is no easy solution to the state’s tertiary emergency department crisis, but we can mitigate its impact by coordinating the use of the state’s post-acute care beds.

    The root cause of the problem in emergency departments is not an increase in demand for emergency care. In general, our emergency department visits are at pre-COVID levels. What has changed is our ability to get patients out of hospitals’ inpatient units and into post-acute care beds, which include skilled nursing facilities, rehabilitation centers, and nursing homes. On average, patients are staying an extra day and a half in our trauma center because of workforce shortages in post-acute care settings. When patients can’t be discharged, new admissions back up in emergency departments, creating the crisis we have today.

    Unlike the state’s tertiary referral centers that are running at 115 percent to 120 percent capacity, many of the state’s smaller, less comprehensive hospitals have empty beds. The problem is that they get equal access to post-acute care beds, which sets up the horrible situation that we have today, where community hospitals with empty beds desperately trying to transfer critically ill and injured patients to tertiary centers are turned away because the trauma centers are completely full. This wouldn’t happen if we coordinated the use of the state’s post-acute care beds to ensure we always have capacity at regional trauma centers for transfers.

    How can we solve this problem now?

    What worked in a pre-COVID world does not work in the present day. However, what worked during the first surge of COVID could help. In the early days of the pandemic, the Office of Health and Human Services, in partnership with the Massachusetts Health and Hospital Association, monitored inpatient capacity at every hospital in the state. Because of this data, we knew exactly how many inpatient beds were available and where so that COVID patients could be appropriately cared for in facilities that had capacity.

    If we were to deploy a similar model of monitoring for post-acute care availability, OHHS could prioritize discharges from tertiary referral centers that are beyond their capacity to post-acute care facilities that have capacity.

    Daily monitoring of capacity needs isn’t simple and will take resources at the state level, but it’s imperative to help solve our capacity crisis.

    We also need to empower paramedics to care for patients in their homes under the direction of an emergency physician and not transport everyone to the hospital. This would become commonplace if insurance companies were willing to pay emergency medical services the same amount to care for a patient in their home as they do when the patient is transported to the hospital. It would also result in significant cost savings by reducing emergency department visits while taking pressure off already overwhelmed emergency departments across the state.

    Now is the time to take action to support our health care system once again — just like we did in the early days of the COVID-19 pandemic. We need to rally one more time and implement a care coordination system that helps create capacity at the state’s tertiary referral centers. The stakes are high; failure to do so will unnecessarily jeopardize patient safety in Massachusetts.

    Dr. Eric Dickson is an emergency physician and president and CEO of UMass Memorial Health in Worcester and chair of the board of directors for America’s Essential Hospitals.

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