Reimbursement, finance and politics: Injecting financial lifeblood into EMS

Five key financial and operational asks to keep EMS afloat and financially solvent


It won't be too long before hurricane season is upon us. It will mark the time when we look for meteorological waves and disturbances in the area of the Cape Verde Islands and then watch the spaghetti models as the waves turn into a depression and the rotation causes a hurricane.

The key to surviving the eventual arrival of the natural disaster is in preparation and planning. We know when a hurricane is coming at least a week ahead of time; its rough point of landfall and when to batten down. In the same way, we must prepare for the economic storm that is about to arrive on the EMS shore.

As this week's money is derived from last month’s transports, money may be rolling in right now, but the current depression in call volume will hit in only a few weeks as lack of response, treatment and transport now means there is less to collect – and so the bucket of money from which we pay and sustain all in EMS will dry up.

To remain financially solvent, we must keep cash flow moving in the pipeline and topped up from federal sources. (Photo/Getty Images)
To remain financially solvent, we must keep cash flow moving in the pipeline and topped up from federal sources. (Photo/Getty Images)

The economics of delivering EMS patient care

I have long said that EMS is a business, like it or not, and the COVID-19 pandemic has certainly highlighted the economics of delivering patient care. The rule of thumb is simple: if we can’t make payroll, then we can’t pay the workforce, potentially leading to furloughs, layoffs and closures.

To help us understand the looming problem, we need to look at revenue cycle. Picture this. The medic treats the patient, completes the ePCR and saves the record to the server. The report is then processed by coders and reimbursement specialists for onward transmission to the insurance company or Medicare for payment. The time from input to payout usually takes a month, sometimes longer, and is a metric that is monitored closely and reported at most boards, as this affects cash flow and therefore, the financial solvency of an organization.  

With the current reduced demand and call volume (outside of the COVID-19 hotspots) on the EMS system, a massive EMS pay cut is coming and is going to affect the bottom line of many organizations. There are many models of EMS in the U.S., and while we all understand that private systems require reimbursement to remain in business, others, including municipally funded and volunteer organizations, have turned to collect insurance and Medicare to help make ends meet – so everyone is about to be affected. 

These are the reasons we have turned to lobby hard for the stimulus packages and programs that have come our way so far and all continue to work hard to influence the forthcoming fourth stimulus. It has become clear that it will be down to the alphabet soup of EMS trade associations and organizations to lobby for the financial lifeblood to keep EMS funded and afloat. Additionally, there are many issues of a national concern that need to be tracked, addressed and championed at this time. In the last two months, EMS leaders have written letters to the president, attorney general, treasury secretary and the U.S. Public Health Service to name but a few, to ensure EMS remains on the radar.

Key financial packages and operational asks to keep EMS afloat and functioning include:

  1. A request to increase relief funding for all ground ambulance service providers and suppliers. It is estimated that the industry needs about $2.89 billion up to June 30 to remain solvent.
  2. Priority access to PPE and testing and eligibility for public health emergency compensation. We must ensure federal agencies are directed to provide EMS of all types with higher priority access to PPE and testing. We must ensure that all governmental and non-governmental frontline EMS workers are eligible for any essential worker compensation or tax relief specific to the public health emergency.
  3. A waiver for coverage of treatment in place. One of the saving graces so far in the pandemic has been that EMS can assess a patient on the scene and determine if they are sick enough (or not) to be transported to the ED. This assessment, particularly in hot spot areas, saves hospital bed space. Sadly, this act is not reimbursable under current rules and regulations, so the time and hours used to conduct this health system capacity saving activity are performed at a loss. The irony here is that the actions being taken in the name of the pandemic are going some way to proving the virtues of the recently postponed ET3 pilot.
  4. Access to public assistance grants and waiving of applicant match. Many 911 contracts and most inter-facility transport services are conducted by private EMS. Many are not entitled to apply for grants that may assist with offsetting PPE and other costs.
  5. Expand the Public Safety Officers’ Benefit (PSOB) program. The PSOB must include paramedics and EMTs who are employed by a private for-profit EMS agency and die in the line of duty due to COVID-19 exposure.

Politics and reimbursement are critical business activities currently (as they always have been). As we are seeing decreasing volumes causing cashflow issues, which, in some quarters, are already leading to furloughs and layoffs, many are now realizing the need for the business end of EMS to function and function well. To remain financially solvent, we must keep cash flow moving in the pipeline and topped up from federal sources. If we do not do so, then EMS itself could be the biggest casualty of the pandemic.

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