As 2010 dawns and economic issues continue to dog emergency services, there is a flicker of hope that we may be making progress toward creating sustainable local funding of EMS. That hope is not emerging from the promises of politicians or the myriad ongoing federal projects, committees or reports, nor is it coming from industry associations or labor unions. Hope is flickering at the margins and borderlands of our industry where small towns, rural communities and ordinary citizens are being acutely affected by the weaknesses of the current funding system.
As the economic crisis exacerbates funding challenges for local EMS, it has also demonstrated the fragility of funding EMS primarily through a volume-dependent, fee-for-transport system. Having a volume-dependent funding system for a basic and vital public service has always been a peculiar construct and not the product of thoughtful design. It simply evolved from the early days of the ambulance business when providers billed for transportation services.
Because the EMS industry has always been divided between for-profit businesses and government or nonprofit public services, EMS has straddled the fence between market-driven business modeling and essential public service modeling. While this mix has created a wide assortment of disparate funding models, the primary source of revenue has remained transport fees. Because volume equals dollars, volume often dictates system design in terms of deployed resources and the level of services provided. Where there are calling and paying customers, there are more resources and higher levels of care. Where there is little volume (whether through small populations, better health prevention or prudent use), there are fewer EMS resources or greater subsidies (often in the form of volunteer labor).
Not only does this funding system raise important ethical issues, it is also fragile. Last winter, when the severity of this current economic crisis hit ordinary citizens, some EMS systems experienced sudden and dramatic declines in call volume. These declines were enough to cause some agencies to cut budgets, freeze hiring and reduce services. But interestingly, such declines were not universal. Some services experienced volume increases; others noticed odd changes in their payer mix, such as increases or declines in Medicare, private insurance and no pays.
The real fragility and consequences of the current funding system can be seen in small towns and rural areas where volumes are low and the subsidy of volunteerism is collapsing because of socioeconomic and demographic changes. But this is also where hope flickers. As communities face the reality that they don’t have enough volume to hire people off fee-for-service revenues and financial help from state and federal government is unlikely, EMS is beginning to garner the hearing it has always deserved. Mayors, city managers, county commissioners, hospital administrators and many ordinary citizens are beginning to engage in a vigorous and often smart debate about EMS, addressing such questions as: How much EMS do we want, and how long are we willing to wait for it? What level of care are we willing to pay for? Why do we have eight fire trucks for 20 calls per year? Why do we pay for snow plowing and not EMS? How can we pay for EMS in a way that ensures it is there when we need it?
In some locations these debates are resulting in an elevation of EMS as a vital public service that is worthy of funding mechanisms that are locally based and locally sustainable. That, indeed, is hopeful.
John Becknell is the founding publisher of Best Practices. You can reach him at jmbecknell@gmail.com.
