Pa. ambulance services struggle with recruitment, expenses
Staffing, vehicle and equipment maintenance, high overhead costs and insurance reimbursement issues create a strain for EMS agencies across the state
By Kecia Bal and Jocelyn Brumbaugh
The Tribune-Democrat, Johnstown, Pa.
JOHNSTOWN, Pa. — At Somerset Area Ambulance Association, 21 full-time paramedics and emergency medical technicians and a roster of about 25 part-timers respond to some 400 calls monthly from the Somerset station and Stoystown substation.
Those emergency crews answer dispatches in what can be life-or death situations in an area that stretches across Somerset County, including about 50 miles of the Pennsylvania Turnpike.
The association has three crews, but could use a fourth, Manager Dan Buck says. Four of the department’s five ambulances have more than 200,000 miles on them, meaning regular trips and expenses for repairs.
“We haven’t been able to update, but we need to,” Buck said.
With other paid emergency medical service departments – and some volunteer departments – stretched just as thin or worse, those crews and ambulances often are tied up responding outside their primary response areas. Sometimes it’s just outside those boundaries; other times, it’s as far as a vehicle crash with injuries on Interstate 68 outside of Grantsville, Maryland.
And the most reliable way to make money is in medical transports, which require a signed medical necessity form, meaning it’s more likely that an insurance company will cover the cost. That also means one of the department’s ambulances could be making the trek to Pittsburgh and back for a transport, leaving it unavailable for hours at a time.
“I want to commend the other ambulance services,” Buck said.
“Without them, we wouldn’t be where we are. And they know we’re here to help them. Everybody knows (these challenges) affect response times.”
Those concerns aren’t just a Somerset problem; they are statewide, those in the emergency response field say.
Echoing concerns of other departments and 911 coordinators in Cambria and Somerset counties, Buck said increasing hardships include:
- Staffing: A medic could make between $12 and $15 hourly, while a “bridge” class to become a registered nurse would mean a pay raise of double or more.
- Vehicle and equipment maintenance: A new ambulance can cost $80,000 to $150,000 or more, depending on how it’s equipped.
- Overhead costs: Such as worker’s compensation insurance, and meeting stricter state and federal regulations on equipment standards.
- Getting paid: The department fills out a trip sheet after each call for billing insurance companies. Reviews can take 30 days, and then the department is issued a portion of a check, Buck said.
“We accept whatever most insurance companies pay,” he said. “But some insurance companies cut a check to the individual. Then we have to go after the people to pay us.
“If we can’t get paid, we hate to send it to collections, but sometimes we have to.”
Buck said the department is owed hundreds of thousands of dollars right now – money that may never come.
“A percentage of that is written off,” he said. “But you can’t write off everything. We need money to put fuel in our ambulances.”
Though state law requires municipalities to have contracts for emergency medical services, they aren’t required to pay for those services. Somerset Borough this year is giving $1,000 per quarter to the association.
Boswell Volunteer Fire Company’s advanced life support EMS department is recovering about $6,000 a month less than it did last year, though call averages – around 50 to 55 monthly – are the same, fire company President Bob Turner said.
“For us to be that far behind, that makes a big difference,” he said. “We don’t know if we’re going to get it.”
Some insurance companies pay patients directly – and then it’s up to the individual to pay the ambulance service. That’s one issue the Ambulance Association of Pennsylvania is asking legislators to change.
“It does happen where the patient doesn’t forward the money,” Turner said. “Some are multiple occurrences, where we get called to their residence several times. I don’t know if that’s a way for them to make money, but because of what we do, we’re not going to not go, for ethical reasons. If they didn’t have any insurance, we’d still do it.”
Those challenges can affect police departments, too.
Police officers are notified when there’s a medical call and they can choose whether to assist, according to Rick Lohr, the Somerset County Emergency Medical Agency’s executive director. Over the past few months, Somerset Borough police have responded to more medical calls than usual, police Chief Randy Cox said. Officers, some of whom also are medics, have revived at least four people over the past month.
Lohr said it goes back to the troubling times.
“What’s happening is a delay in responses for ambulances because of staffing,” he said.
“It’s not only a staffing problem with Somerset. It’s all over the county and the state. It’s a hard business to be in right now.”
‘Make ends meet’
The emergency field is busier than ever with baby boomers aging, Somerset County 911 coordinator Dave Fox said.
The challenges EMS departments face are compounded at volunteer departments, which face difficulties similar to fire companies: finding people who can run to the rescue at any time of day or night. Somerset County has three volunteer EMS departments: Jennerstown, and two in the county’s sprawling southern stretches – Confluence and Salisbury.
“It’s really tough for them to make calls,” Fox said. “But even for paid services, it’s hard to make ends meet with limited staffing and resources. It puts a burden here on us. We’re not spending three minutes dispatching an ambulance. Now it’s three, six or 10 (minutes) to get one on the road.”
Southern Alleghenies EMS Council, which covers Somerset and Cambria counties, collects response times and some other information for all EMS departments in its six-county region, but Executive Director Carl Moen said he could not provide those figures.
Those used to be compiled in a document format but now are kept electronically and not readily accessible, he said.
“It’s actually a time of great change in EMS, as with the rest of the health care system,” he said. “We’re moving into the Affordable Care Act. That’s having an impact. There are the volunteer issues and issues in the Legislature with direct pay.”
No matter how long it takes, dispatchers stay on the line with callers, talking them through anything from childbirth to performing CPR, Lohr said.
Consolidation is both a hope and a fear, he said. The broader challenges with providing health care and haggling with insurance companies means ambulance service members sometimes feel they have to be territorial.
“It’s evolved into a business,” Lohr said. “They’re not greedy – my territory or your territory – but sometimes they need the calls to try to make enough to operate.
“It’s getting harder and harder to operate.”
In Johnstown, one EMS department says it has had to get creative in offsetting outstanding payments from patients and reimbursements from the state that just aren’t enough.
Ira Hart, manager of West End Ambulance Service, said 40 percent of the department’s patients are covered under the state’s medical assistance program or have no insurance, compared to about 20 to 25 percent of patients a few years ago.
“We actually lose money when we go out the door to treat patients on the state medical program,” he said.
The reimbursements for those patients do not “begin to cover our costs,” he said. The department has begun to respond to more non-emergency calls, including lifts for bariatric, or obese, patients.
“That’s how we supplement,” he said. “We could not survive on emergencies alone.”
West End has five vehicles, including one box ambulance for bariatric patients and four vans, which help keep costs down, Hart said. Even when one vehicle is responding to a non-emergency call, Hart said departments are required to keep one vehicle ready for an emergency.
Robbin Melnyk, Cambria County’s 911 coordinator, said some departments specialize in non-emergency transporting based on demographics, while other areas have services such as MedVan that respond to non-emergency calls.
For patients with insurance coverage through a private provider, Hart said, the company often sends reimbursement checks to the patients. A lot of times, he said, the patients will keep the checks for themselves.
“There’s a large outstanding amount that we’ve never gotten back,” he said, adding that seeking the payments through the legal system can also be costly.
“It’s a struggle,” he said.
In the past year or so, Conemaugh Township EMS has been working with county detectives to retrieve that money from individuals, although manager Terry Ruparcic said he wouldn’t call it a huge problem.
“I’d call it an inconvenience,” he said. “It’s improved over time, but we’re still actively seeking that money.”
While he didn’t have a figure on how much the department is owed, he said it has decreased since the department has worked with detectives to claim the payments.
Staffing and equipment
For the future of ambulance and EMS departments, Hart said, finances are always the most difficult challenge to overcome, especially with equipment being so expensive.
For example, Hart said, cardiac monitors in EMS vehicles that can send patient data to the hospital cost about $35,000 each, while special equipment for bariatric patients can run several thousand dollars.
“As (pieces of equipment) start to expire and need to be replaced, that’s expensive,” he said.
Melnyk said that many of Cambria County’s 35 ambulance services have more than one vehicle, and some have more than one crew.
In the northern part of the county, smaller departments will alert dispatchers if they have one crew available or if a vehicle is out of service so a neighboring department can handle any calls that come in.
“What we do is look ahead at that and get another unit to cover that hole,” Melnyk said.
Melnyk said her staff has also been improving on dispatching ambulances, dropping off patients at hospitals that may be close to a scene and are still in service.
“We have a unique technique that doesn’t work in other counties,” she said.
The biggest struggle in the future of EMS departments in Cambria County, Melnyk said, is hiring and retaining paramedics.
“The biggest issue, without a doubt, is staffing,” she said.
Many services may try to entice paramedics by offering a higher wage than another unit, she said, creating a sort of vicious circle.
“There just aren’t enough of them to go around,” she said.
©2015 The Tribune-Democrat (Johnstown, Pa.)