Unresolved challenges leave EMS groups across the country struggling

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David Colburn

MT. FER- All presenters and attendees at a forum on emergency medical services last week at the offices of the Range Association of Municipalities and Schools were familiar with various aspects of ambulance services, but after two hours of sharing their collective wisdom, a sobering theme emerged: Without systemic change driven by the adoption of EMS as an “essential service,” the future of emergency medical services in greater Minnesota is in jeopardy.
“We need to fund EMS as an essential service. Why should EMS break even or make money? said Virginia Fire Chief Allen Lewis. “We don’t ask our cops to do that. We don’t ask our fire departments to do that. For some reason, EMS is not considered an essential service. The state and our legislators must deal with it. They need to make EMS an essential service and they need to fund it. Otherwise, you’re going to call one day and you won’t get that ambulance, and I’m not melodramatic.
Lewis, who oversees a regional Advanced Life Support (ALS) service, was one of six expert panelists brought together by RAMS executive director Ida Rukavina to lead the discussion.
“We need to combine resources, we need to combine districts, we need to combine services at some point, and we need to start looking at how we’re providing what this patient needs,” Lewis said.
Lewis was joined on the panel by EMS regional directors Erik Jankila, Hibbing Fire; Therese Elverum, Ambulance Eveleth; Donna Hoffer, Orr Ambulance; Dustin Moravitz, Ely Area Ambulance; and Jessica Davis, Chisholm Ambulance. Each took turns answering questions posed by Rukavina covering aspects of EMS services, from staffing and funding issues to providing services and the necessary government and regulatory support.
A diverse audience of over 100 people attended in person or via Zoom, including elected and appointed officials from all levels of government.
Almost every topic covered echoed the findings of a statewide EMS needs assessment conducted in 2002, but in the two decades since, the issues have become magnified and more complex as that little has changed in basic support.
The most extreme example of no change was offered by Elverum.
“A date that is etched in my memory is October 9, 1984,” she said. “That’s when the county decided on reimbursement rates for ambulance services of $16 per call and 22 cents per mile. It has never been increased. There’s something wrong with that.
Recruitment
Asked about her biggest challenges, Hoffer’s immediate response was all too familiar to her colleagues at the table, that of having adequate staff to provide coverage.
“A lot of days our coverage is limited,” she said. “Nights are better, weekends and Saturdays are a challenge.”
Moravitz agreed, noting that it was often difficult to cover a 24-hour period with two crews.
Most expressed the need for increased compensation, while noting that crew members are there to help rather than pay.
But the issues with staff go far beyond pay, panelists said. The service takes a toll on their mental health, not only because of the types of cases they encounter, but also because of the change in the types of calls they respond to.
“When I started doing this a long, long time ago, we weren’t doing as many transfers as we do now. Our transfer volume over the last six or eight years has probably quadrupled,” said Lewis: “Thirty-three per cent of our calls are inter-facility transfers. It really takes a toll on staff when they’re out for three hours sometimes, and most of our transfers are actually about mental health. That’s been a bit of a challenge to follow that.
Elverum said many of their long drives weren’t originally planned because Essentia Health-Virginia’s emergency room is too small to handle a five-fold increase in annual patient numbers.
“It was built for just 6,000 patients a year and they fly 6,000 patients a year in Virginia alone,” she said. “It’s almost 30,000 patients a year now and nothing has been done about it. There can be a wait time of four to six hours and so we transport to the nearest hospital. Instead to go to Virginia, we crush Hibbing.
All agreed that the volume of inter-facility transfer calls puts extreme pressure on their staff, often leaving smaller service areas uncovered and dependent on mutual aid as they do not have the staff to fill two shifts simultaneously. .
Staffing is also an issue with first responder units, as is the actual response when called upon. Lewis said he was aware of one unit where the response rate from first responders was only around ten percent, while most hovered below 50 percent. It was also noted that responses dropped significantly during the COVID pandemic as many older responders feared exposing themselves to the virus.
Finance
Ambulance funding is a piecemeal mix that varies across service areas and is a mixture of fee-for-service and varying levels of government support. Either way, it’s not enough, Jankila said.
“We rack up millions and millions of dollars with the services we collect, and that still doesn’t cover what it costs us to operate,” he said. “There were no funding levels. It doesn’t matter whether you are in tower ambulance service or cook’s ambulance service, we are not roughly reimbursed for the cost of operations on 911 calls. When we look at the funding mechanism, the honest truth is that funding is in the form of transfers. Transfers can help rejuvenate the income stream. So as administrators we want to use these transfers to help the bottom line to keep us operating”
The trade-off for more transfers is increased stress on staff from more calls and longer hours. And in the case of 911 calls, if a BLS service has to bring in an ALS team to provide more intensive care to a patient, that compensation can completely evaporate.
“Eighty percent of our calls are Medicare and Medicaid, for which we are reimbursed $547,” Evelum said. “Right now if I call for an interception (ALS) I have to pay them $600. I have $50 in the hole.
Panelists appealed to lawmakers and officials to sponsor initiatives and bills to increase financial support for ambulance services. St. Louis County Commissioner Mike Jugovich said a realignment of seats on the board of commissioners has opened a window to seek additional support in his county.
“For the first time in St. Louis County history, you have four rural commissioners,” he said. “We talked. I did four different runs to take care of the ambulance runs in the unorganized townships and failed each time. We won’t fail this year.
Jugovich acknowledged it was a small start, but he and his rural colleagues are willing to look at other options for more support.
Jugovich also said the federal government must step in to reimburse emergency services provided in the Boundary Waters canoe area and Voyageurs National Park.
“We are supposed to support emergency services in boundary waters and we get nothing in return from the federal government and we have tried,” he said.
Many other speakers touched on other issues, but ultimately panelists agreed that it all comes down to making a legislative commitment to EMS as an essential service.
“Having a perspective coming from out of state where things are handled very differently, I don’t think EMS is given priority in Minnesota than it is in many other areas,” Davis said. “When you call 911, you want the ambulance to be there, you don’t want to have to think about it, you don’t want to have to explain anything to yourself. It’s the wait. Each of us deserves to have this expectation and has not achieved it. And I think a lot of that will be facilitated by becoming an essential service.”
Lewis stressed that engagement must be across the government line.
“We need to have a committed government at all levels, local townships, cities, state and federal to address this issue. No one is going to fix all of this,” Lewis said.

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