By the time most EMS leaders finish reading a CMS cost report, they’ve either poured a second cup of coffee — or started questioning their life choices. The good news? The latest Medicare Ground Ambulance Data Collection System (GADCS) Report finally gives us something worth losing sleep over.
The bad news? It confirms exactly what you already know.
When CMS and RAND expanded their original Year 1-2 GADCS analysis to include 4 full years of data — nearly doubling the number of ambulance agencies analyzed — the result wasn’t a plot twist. It was a plot lock.
The story didn’t change.
It just became impossible to ignore.
Bigger dataset, same financial headache
The original GADCS report analyzed complete data submissions from 3,712 ambulance agencies. The new Year 1-4 appendix analyzes complete submissions from 7,387 agencies — 70% of all sampled providers nationwide.
If anyone was hoping the earlier findings were a statistical fluke, rounding error, or “just a few inefficient systems,” the expanded cohort put that theory into asystole.
Across all payer types, the average ambulance response loses more than $1,000 per call, representing a 56% cost-to-reimbursement gap. Low-volume and public safety-based agencies fare even worse, with gaps exceeding 63%.
Even the biggest, busiest systems — those supposedly benefiting from economies of scale — still operate in the red.
In other words: The more data we collect, the more consistent the underpayment becomes.
Labor: Still eating the budget (because people are an investment!)
If EMS had a love language, it would be labor costs.
The full cohort confirms what leaders feel in every payroll cycle:
- Labor accounts for 70.7% of total ambulance costs, up from 69.4% in the earlier cohort.
- Wage inflation, workforce shortages, and staffing minimums aren’t “temporary disruptions.” They’re structural realities.
- Median costs remain far below averages, meaning a small number of very large systems skew national means — while smaller agencies still shoulder the same fixed readiness costs.
Translation: You can’t staff fewer EMTs and paramedics just because fewer people call 911. Readiness doesn’t punch a timecard.
Medicare advantage: The plot thickens (and the payments are thin)
Perhaps the most important shift between the two reports isn’t on the cost side — it’s on the revenue side.
Medicare Advantage (MA) has officially graduated from “annoying side issue” to primary financial threat.
In the expanded cohort:
- MA revenue as a percentage of revenue received grew by more than 30%.
- For some agency types, MA now surpasses traditional Medicare as a revenue source.
- MA reimbursement continues to trend below Medicare Part B levels, despite higher administrative friction (higher deductibles, preauthorization, denials. Etc.).
This confirms what EMS agencies across the country have been saying for years: Underpayment by Medicare Advantage isn’t anecdotal — it’s systemic.
When MA plans underpay, EMS doesn’t get to deny service. We just absorb the loss and answer the next call.
Non-transport: Not an accident
One of the most important validations from the full cohort is what didn’t change:
- 24% of ambulance responses result in no transport
- 11.4% of all ambulance responses involve treatment, without transport
Despite 4 years of data across thousands of agencies, those numbers barely budged.
That matters because it permanently buries the argument that non-transport costs are an anomaly or operational failure. They’re a core feature of modern EMS — driven by clinical appropriateness, system efficiency and patient-centered care.
“ You don’t get to reduce readiness just because the patient didn’t get schlepped to an ED. ”
Stealing from providers
In the full data cohort, 19.7% of ambulance transports go unpaid, up from 18.8% in the initial cohort. Put simply, nearly one in five ambulance rides generates no revenue at all. In any other industry, receiving a service and not paying for it would be called theft of services — EMS just tends to call it “Tuesday.”
To be clear, EMS agencies, like all healthcare safety-net providers, should maintain charity care and compassionate billing policies for those who genuinely cannot pay. But compassion is not the same thing as complacency. EMS leaders and policymakers share a responsibility to ensure that patients who can pay, and should pay, actually do. Otherwise, we’re not funding a healthcare safety net system, we’re quietly subsidizing unpaid tabs with fewer ambulances, fewer staff and thinner margins.
Volume is skewed — and always will be
Another irrefutable truth confirmed by the expanded dataset is that the top 10% of ambulance agencies handle about two-thirds of all ambulance transports nationwide.
High-volume urban systems and low-volume rural agencies look nothing alike, but both must maintain 24/7 readiness, trained clinicians, vehicles, equipment and infrastructure. The idea that one “low-cost model” can scale nationally doesn’t survive contact with real data.
Why this report should change policy conversations
The Year 1-4 data cohort doesn’t introduce new problems.
It removes excuses.
With nearly twice the data:
- Unreimbursed responses are no longer debatable
- Readiness costs are no longer hypothetical
- MA underpayment is no longer dismissible
- Labor dominance is no longer “temporary”
This is now policy-grade evidence — strong enough to support:
- Medicare add-on extensions
- Medicare Advantage payment enforcement
- Treatment-in-Place and MIH reimbursement
- Cost-based readiness subsidies
- Local and state funding discussions
In short, the dataset is finally big enough that “we need more data” is no longer a serious argument.
Takeaways for EMS leaders
The full cohort GADCS report doesn’t change the narrative.
It locks it in.
EMS is not a transport business, not a ride to the hospital; it’s labor-intensive, healthcare safety net infrastructure. Payment models built around mileage and loaded patients will never align with a system designed for readiness, clinical decision-making and clinically appropriate patient navigation.
The data now says that clearly, consistently, and nationally.
Which means the next question isn’t whether payment reform is justified.
It’s whether policymakers are ready to act, or if EMS is expected to keep doing what it does best:
Show up anyway.
| MORE: Hyper-turbulent times: EMS economics and AI guardrails with Matt Zavadsky and Dr. Shannon Gollnick
Learn more: What We Learned from the Year 1-4 CMS Ambulance Cost Report
Special Note: PWW|AG Webinar
Date: Jan. 6, 2026, 1 p.m. CT
The Centers for Medicare & Medicaid Services (CMS) has released its second Medicare Ground Ambulance Data Collection System (GADCS) report, analyzing data from Years 1-4 of the full reporting cohort. With input from more than 7,300 ambulance services nationwide, it delivers the most comprehensive look yet at what it really costs to operate a ground ambulance service — and why so many agencies feel like they’re running a high-stakes operation with a low-stakes reimbursement model.
In an upcoming PWW|AG Webinar, Doug Wolfberg and Matt Zavadsky unpack what the data clearly shows (and what CMS diplomatically left between the lines) about ambulance costs, revenues and sustainability. Attendees will learn trends in labor expenses (the financial gift that keeps on taking), unpaid and non-transport responses, revenue shortfalls, and service volume distribution, including the now-legendary gap between costs and reimbursement illustrated by PWW|AG’s “Table X” and “Table Z.”
The session will also review recent MedPAC commentary, what it signals for potential changes in Medicare reimbursement, and — most importantly — what EMS agencies can do right now to advocate, innovate and diversify revenue in a world where expenses keep climbing and payers keep asking for patience.
Designed for EMS executives, finance leaders, policymakers and system administrators, this webinar translates dense federal data into practical, actionable insights so you can spend less time explaining why the numbers don’t work and more time figuring out how to make them work anyway.
