By Doug Wolfberg, Esq.
In December 2024, CMS released the first report on the Ground Ambulance Data Collection System (GADCS). This made news in ambulance circles in early 2025. However, something that happened much more quietly in March is likely to have a greater impact on ambulance services nationwide: the actions of a little-known entity called MedPAC — the Medicare Payment Advisory Commission. MedPAC’s twisting of the GADCS data is likely to minimize any increases to Medicare Ambulance Fee Schedule rates for the foreseeable future.
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MedPAC is comprised of 17 appointed commissioners, supported by a staff, and bills itself as a nonpartisan, “independent congressional agency to advise Congress on issues affecting the Medicare program.” Among its other responsibilities, MedPAC advises Congress on payments to providers under Medicare Part B, which, of course, includes ambulance services.Part B rates also serve as the basis for payments to noncontracted ambulance services under Medicare Part C (Medicare Advantage).With Medicare being the most significant portion of the payer mix for most ambulance services, what MedPAC does has a profound impact on the economic well-being and sustainability of ambulance services throughout California, and nationwide.
After the GADCS report came out, many in the industry (including yours truly) did deep dives on its findings. (In fact, in January, PWW held a comprehensive webinar on the report.After all, this was the first nationwide, across-the-board study of ambulance costs that incorporated all provider types — private for-profit, public, hospital-based and non-profit. Another Federal agency, the Government Accountability Office (GAO), released ambulance cost studies in 2007 and 2012, but in both reports, GAO excluded data from “ambulance providers that shared operational costs with other services, such as those provided by fire departments,” hospitals and others. In the GAO’s opinion, cost data from entities that provide ambulance services along with other services are “inconsistent” and “unreliable.”Apparently, the GAO didn’t care about the fact that EMS is not one-size fits all and is provided by different entity types across the country.
So, it was quite meaningful when CMS released the first GADCS report — prepared by its contractor, the Rand Corporation — in December. The report showed that costs for all ambulance provider types — public, private and nonprofit — greatly exceeded the fee-for-service revenues.Medicare rates, in particular, were woefully insufficient to cover the costs of providing ambulance services for all provider types.
Excluding important ambulance cost data
When MedPAC met on March 6, 2025, its agenda included a review of the GADCS report. Finally, it appeared that Congress would have a fair and accurate representation of all ambulance service costs, instead of the sanitized, stripped-down data used by GAO in their two earlier reports. Anticipation was high. But MedPAC popped the balloon.
Mind you, MedPAC didn’t perform the ambulance cost data collection. CMS did that through Rand.MedPAC’s job was to consider the report that CMS issued based upon the nationwide ambulance cost data. MedPAC stripped more than half of all ambulance cost data from the sample. There it was, in black and white:
“We have made two edits to the GADCS data:
- Dropped organizations that share costs and revenues with fire departments, police departments or hospitals
- Dropped organizations that have extreme cost levels (more than 3 SD [Standard Deviations] from the mean)”
The first MedPAC bullet is familiar: “we don’t trust the cost data from organizations that provide other services in addition to ambulance services.And the second bullet?They’re taking direct aim at high-cost rural ambulance services.The net effect of MedPAC’s data skimming was to eliminate cost data from over 2,000 of the 3,712 ambulance services in the sample. To paraphrase my PWW colleague Steve Johnson, how can the majority of respondents be the outliers?
Clearly, MedPAC is selectively using only a subset of the actual ambulance cost data to support a narrative that ambulance costs are somehow lower than they really are.By eliminating the data from the ambulance services that report higher costs — which is more than 55% of all ambulance services in the country — MedPAC is setting the table for smaller (if any) recommended increases to the Medicare Ambulance Fee Schedule.
Looking within for EMS funding
In practical terms, this means that ambulance services likely should not hold their collective breath waiting for Medicare to bail them out.Our industry can — and should — use the full, unfiltered GADCS data to make the case to payers and policymakers that ambulance payment rates need to cover costs and ensure the continued sustainability of ambulance services that benefit the public and the healthcare system.
But it also means that our profession urgently needs to look within and innovate to deploy evidence-based service models that eliminate needless costs. By embracing modalities such as treatment in place and telehealth for low-acuity patients, better managing inter-facility transfers, reducing unnecessary wall time in hospital EDs, and implementing more sensible deployment strategies, we can take sustainability into our own hands.
Cultivating innovation in our service delivery looks to be a more viable strategy than waiting for the knight on the white horse bearing more Medicare money. Because it doesn’t look like he’s coming anytime soon.
ABOUT THE AUTHOR
Doug Wolfberg, Esq. is cofounder, CAA Medicare consultant, PWW Advisory Group.
