By Randall Schaefer, DNP, RN, CEN; Matt Zavadsky, MS-HSA, NREMT
In EMS, we’ve gotten pretty good at doing extraordinary things with limited resources. We can intubate in a ditch, run a cardiac arrest in a living room full of Labradors, and somehow still restock the truck before the next call. But prehospital blood administration? That’s a different level of complexity, and cost.
While clinically transformative for patients in hemorrhagic shock, prehospital blood programs are forcing EMS leaders to confront a difficult reality: just because it saves lives doesn’t mean it pays for itself.
A recent national flash poll conducted by the Prehospital Blood Transfusion Coalition (PHBTC), with analysis by PWW Advisory Group, offers a candid look at the economics behind these programs. The findings highlight a growing disconnect between clinical value and financial sustainability, something EMS leaders may find all too familiar.
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Everyone wants blood ... until the ‘bill’ shows up
The good news: prehospital blood administration is expanding rapidly. Aeromedical programs were early adopters (2017-2020). Ground ambulance agencies have accelerated adoption since 2021. This growth reflects strong clinical evidence and a shared commitment to improving outcomes. In other words, EMS is doing what EMS does best: stepping up.
The challenge? Unlike many other EMS “add-ons,” this one doesn’t quietly blend into the budget. It shows up loudly ... usually during budget season ... often with your finance director asking, “Wait, we’re carrying what on the ambulance now?”
The prehospital blood price tag
It’s not just the blood, and patient volume matters — a lot.
Across surveyed agencies, respondents reported that the average annual cost of running a prehospital blood program was about $51,000, with wide variation:
- Fire-based EMS: $39,884
- Public, non-fire EMS: $36,276
- Aeromedical: $76,985
Like most things in EMS economics, volume drives efficiency. Aeromedical programs treat the most patients per agency (avg. 92/year per provider). Public, non-fire agencies treat the largest total volume of patients receiving prehospital blood (average of 48 per agency). Fire-based systems tend to have lower utilization with an average of 25 patients receiving blood per agency.
The average number of patients treated with prehospital blood administration by agency are shown below in Table 1. The average expense per patient for prehospital blood administration is $1,062.63. That’s in addition to the average cost per transport of $2,673 as noted in the Center for Medicare and Medicaid Services (CMS) Ground Ambulance Data Collection Report.
Note that the expense per patient varies dramatically based on the average number of patients treated.
Therefore, the EMS talking point for the cost to a ground ambulance agency of treating and transporting a patient with prehospital blood administration is $3,735.63.
And here’s where things get tricky. A very small percentage of patients receive prehospital blood transfusions. Because while everyone focuses on the cost of the blood itself, the real expense lies in everything around it:
- Storage and temperature control
- Inventory management and waste
- Training and continued competency testing
- Medical oversight
- Logistics (because blood doesn’t exactly like sitting in a hot ambulance in August)
Total reported costs across respondents approached $2 million annually (see Table 2).
In EMS terms, it’s the classic iceberg problem, only this time, the iceberg is refrigerated and expires.
Evaluating total costs for all respondents related to the implementation of blood programs, that translates directly into total cost per patient:
- Fire-based EMS: $28,688 per patient
- Public, non-fire EMS: $18,552
- Aeromedical EMS: $3,912
- Overall average: $11,925
Yes, you read that correctly. Aeromedical programs show a lower total cost due to their higher utilization.
So, while the marginal cost per patient might look manageable, the fully loaded cost, including all the fixed program expenses, tells a very different story.
This is the EMS version of buying a $5,000 coffee machine to save $2 per cup. It works great ... as long as you drink a lot of coffee. The total cost will likely decrease as capital expenditures and training costs are amortized over time, and additional patients are treated.
Reimbursement: “Good news, we got an increase!”
(Pause for applause… then reality sets in.)
Medicare has taken a step forward by allowing ALS2 billing when blood is administered.
That’s the good news.
The less-good news is that only 22% of agencies report billing differently for these cases, and it increases the ground ambulance reimbursement for these patients by about 12%. Aeromedical reimbursement is essentially unchanged with or without blood transfusion.
In real terms, the average collected revenue for ground agencies increases from $547 to $612 for patients treated with pre-hospital blood transfusion.
Which is helpful ... but when your total per-patient cost is north of $10,000, it’s not exactly a financial gamechanger.
It’s the equivalent of getting a coupon for a free appetizer when you just bought the whole restaurant.
The core problem: A classic EMS mismatch
If this all feels familiar, it should. EMS has long operated in a space where clinical expectations are high, reimbursement is limited and readiness costs are invisible to payers.
Prehospital blood administration simply magnifies that dynamic. The PBTC flash poll results reinforce several key realities:
- Fixed costs dominate program economics.
- Cost accounting varies widely across agencies.
- Utilization is critical to efficiency.
- Reimbursement falls far short of true costs.
- Many agencies aren’t maximizing even existing billing opportunities.
In short: we’ve built a clinically excellent model ... on a financially unstable foundation.
What needs to happen next
Bill what you can (yes, really).
If your agency isn’t billing ALS2 for blood administration, start there. It won’t solve everything, but it’s leaving money on the table if you don’t.
Know your true costs
If someone asks what your blood program costs and the answer is “it depends,” you’re not alone, but that’s a problem. Better cost accounting is essential for both internal decision-making and external advocacy.
Use it appropriately — and consistently
Higher utilization (when clinically appropriate) improves efficiency. That means aligning protocols, training, and dispatch criteria to ensure the right patients get the right care.
Find creative funding
Until reimbursement catches up, agencies will need to think creatively:
- Hospital partnerships (they like survivors)
- Trauma system support
- Local subsidies
- Grants
Because right now, many of these programs are being funded the same way EMS funds everything else: with a mix of optimism and duct tape.
Possible grants for implementation of these programs. DOT’s Safe Streets for All (SS4A) initiative, FEMA’s Urban Area Security Initiative (UASI), medical/transfusion medicine foundations, hospital foundations, state-level disaster preparedness and state highway grants.
Push for policy change
Ultimately, this is a policy problem.
If prehospital blood administration improves outcomes, and the evidence suggests it does, then payment models need to reflect that value. That means advocating for:
- Enhanced Medicare reimbursement
- Recognition of advanced clinical interventions
- Alternative payment models that account for readiness
Final thoughts
Prehospital blood administration is exactly the kind of innovation EMS should be proud of: patient-centered, evidence-based, and outcome-driven.
But it also represents a turning point.
Because at some stage, EMS has to stop asking, “Can we do this?” and start asking, “How do we sustainably pay for it?” Right now, many agencies are answering that question the same way they always have, by making it work anyway.
And while that’s admirable, it’s not a long-term strategy.
After all, even in EMS, you can only run on empty for so long.
Bottom line: Pre-hospital blood saves lives. Now we just need a system that doesn’t hemorrhage financially while doing it.
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ABOUT THE AUTHORS
Randall Schaefer, DNP, RN, CEN (lieutenant colonel, retired), is a retired U.S. Army trauma nurse with multiple deployments who advocates for civilian prehospital blood programs, so we don’t forget the hard lessons we learned on the battlefield. She has assisted nearly 90 agencies nationwide in implementing prehospital blood transfusion programs using a standardized implementation process. She is the president of the Prehospital Blood Transfusion Coalition (PHBTC) and a member of the Association for the Advancement of Blood & Biotherapies (AABB) Emergency Prehospital and Scheduled Out-of-Hospital Transfusion Standards Committee, and serves as a technical expert for the National Institute for Defense Health Cooperation (NIDHC)/National Center for Disaster Medicine and Public Health (NCDMPH) Prehospital Blood Transfusion Implementation.
