The Emergency Medical Services system is in the spotlight regularly for the role it plays attending to the health and safety of our communities. Since the beginning of the pandemic in 2020 this role has been undertaken in an ever-increasingly stressful environment. As we move away from COVID-19 as a pandemic and attempt to return to pre-pandemic levels and models of service delivery it is very clear that a lot has changed for us in EMS, and the challenges we are facing today are not likely to be fixed with time and acknowledgement alone. This period of high stress has brought to the surface, and in many cases exacerbated or at least hastened about, problems that were already developing. Here are a few of the systemic issues facing EMS agencies today, as well as some suggestions for how to address them.
COVID-19 brought about an exodus of EMS providers from the system. Given what was asked of our EMTs and paramedics in the early months of the pandemic, who can blame them? In March 2020 they were told “we don’t know much about this virus, how infectious it is, and who’s most at risk, but it’s likely tens of thousands of people will die from it if we don’t keep everyone in their homes. Except essential workers like you….you go find these sick people and take care of them. Use N95s if you have them and wash everything. You should be fine.” There are certain workforces that have an expectation of personal risk inherent to their jobs, and I do believe that EMTs and paramedics are in that category, however the amount of concentrated perceived risk in this case was well beyond what could reasonably be expected in the normal course of performing one’s duties. A contributing factor to the sudden decrease in EMS responders during the pandemic is that a majority of our communities still rely on at least some volunteers. We asked a heavily volunteer workforce to continue to respond to medical emergencies in the face of a largely unknown threat and many of them understandably chose not to. Additionally, the average pay rate for EMTs working in paid positions is low in relation to what these responders are asked to do. For some it wasn’t a hard decision to seek other employment rather than accept the risk presented by the pandemic.
To be clear, the staffing problem in EMS began decades ago and is just reaching a crisis level now. EMS is one of two industries with a workforce split between career and volunteer staff. The other one is our close cousin the fire service, which is facing the same challenges for many of the same reasons. I believe that volunteerism is an important value to perpetuate in our communities, and what better way to volunteer than by helping a neighbor in their time of emergency. Most communities that rely on volunteers for emergency services realize a financial benefit by doing so, however this system characteristic comes with some costs that aren't always easy to recognize. First, voluntary labor can be unpredictable. When volunteers are not available as we are seeing more frequently now, communities are faced with decisions about how to fill the gaps, and are sometimes shocked by the price tag of having to provide coverage with employees or contracted services in place of volunteers. The second cost to this model is recruitment and retention into the field of EMS. An industry model where service providers with the same certifications and performance requirements sometime volunteer to do the work others are paid to do doesn’t impress feelings of job security and value upon people who may be considering EMS as a career choice. Volunteer services are often viewed as opportunities for experience and training for those wishing to make a career of EMS, but these potential future employees of EMS agencies still have to support themselves with other work while volunteering, which means they may be focused on two career paths at the same time. Additionally, asking highly trained professionals to first volunteer in their chosen profession doesn't happen in most other career fields.
The EMS workforce problem is certainly broader than just the impact of decreasing volunteerism. Generally, it’s clear that the essential service of EMS isn’t valued the same as the other essential public safety services of fire and police. This is evident in average pay rates and in municipal support differences. Some of this is a result of a lack of unity in the EMS industry around a common effort to market who we are and what we do. In my opinion however, much of it stems from an identity crisis. EMS has always existed in two distinct arenas, one of public safety and the other healthcare. While there is plenty of crossover between the two within the role of EMS, this attempt to serve sometimes competing sets of priorities creates significant challenges to how the system functions. As an example of this, both police and fire services are predominantly funded by tax dollars because they are seen as essential services that don’t typically have significant revenue streams associated with them. This means that as service demand increases within a community, the community can determine the service level they desire and fund it accordingly. EMS funding is largely tied to a reimbursement for services model, where the patient is billed for the service provided. This reimbursement collected by the EMS agency is then dependent on factors such as the patient’s ability to pay, agreements with private insurers and reductions mandated by government payers. In Connecticut, EMS is acknowledged as an essential service and many municipalities do subsidize it as such, however the more common approach is to rely on patient billing to cover the cost of the service. In some communities with an adequate call volume and a good payer mix, this still works. In communities that lack call volume or where EMS typically responds to a less affluent patient population, services are struggling to keep the doors open financially.
EMS service delivery comes in several different models, leading to several competing priorities for agencies and ultimately resulting in a lack of unity around what should be common issues facing the industry. Before expanding on competing priorities in EMS, I think it is important to point out that one unifying characteristic of all EMS agencies regardless of the delivery model is a common desire to help and serve people. This aside, each service delivery model has different motivators, often based on revenue source and business objectives. For some examples of what I mean; a hospital-based service may be incentivized to keep patients within their network of service providers, or base some of their operating value on their ability to transfer their patients between network care providers without paying an outside service provider to do so. Municipal EMS services may have a goal of being available for emergency responses, whereas commercial EMS may need to prioritize their availability for interfacility transfers. For all EMS agencies there are the public safety considerations of service delivery and there is the business side of service delivery, which may be considered differently depending on the EMS agencies delivery model. While there remains plenty of common ground between providers working in all of the various EMS service delivery models, the multitude of competing priorities between the many business models creates an environment where it is difficult to build true unity around many of the issues facing our industry. Put more simply, what is in the best interest of one service provider is not necessarily in the best interest of another.
What can be done to ensure we have adequate EMS services going forward? This is a complex issue and I believe that to address it we need to look in all directions for answers.
First, our communities need to understand the problem. We in EMS haven’t done an ideal job of explaining our value in a way that our citizens understand what we actually do. I don’t mean how we provide care to individual patients, I mean how our EMS services fill a vital role in the community. That role includes timely emergency care for critically ill or injured patients, yes. It also includes being an access point to medical care for underserved populations. It includes being the eyes of social support services in the homes of our vulnerable senior residents. It includes being available at sporting and community events. It includes public education. I can go on here of course. The point is that for all we do, the community at large is generally aware of one element – we show up for medical emergencies. Even at that, the extent to which we provide life-saving or even routine medical care is largely under-appreciated by most. If we as an industry want to ensure that our communities continue to have adequate EMS services, then it is up to us to market our value. This takes organization. We need to speak with one voice as an industry. There needs to be a unified effort between all types of service providers to get our message out. This means agreeing on what that message is and then working with local and State leaders to communicate it to our communities in an effective way. There are several EMS leadership and education groups that recognize this need. Efforts to do this have been undertaken at the federal and State levels, with limited success in actually unifying our industry around a common cause. More needs to be done in this area.
If EMS is to survive, we need to address how we value our EMS workforce. EMS cannot continue to be viewed as a steppingstone to more prestigious, higher paying jobs in healthcare and public safety. EMTs and paramedics should be held in the same regard as their counterparts in these other industries. We get there by having similar expectations for education, training and professionalism as is expected in nursing or police careers for example. Along with similar expectations comes ensuring pay and benefits commensurate with the education, training, skills and performance we are expecting of our EMS workforce. While volunteerism remains important, it has to exist within a service delivery model that ensures someone is available to answer every 911 call in a timely manner, and with the same performance expectations in every community.
Finally, the way in which EMS services are funded needs reform. The first step toward this is deciding what type of service provider EMS is. If we are a healthcare service that also provides public safety services, then following a fee for service model like most healthcare providers makes sense for much of our funding. If EMS is a public safety service that also provides healthcare services, then it should be funded as such, with some allowances for a lesser part of funding to come from fee for service reimbursements. In either case, recognition of the primary function of EMS is vital to fairly and accurately identifying funding sources, and this primary function determination may change from one community or healthcare system to the next. A contributing factor to the funding discussion is that over time communities have grown accustomed to receiving services from EMS agencies that are not reimbursed by anyone. The cost of providing services is increasing and reimbursement from payers isn’t keeping up. There needs to be some recognition that there is a cost to providing emergency planning, preparedness and standby services. There is a cost to providing community outreach or education. These costs are not reimbursed by an insurance company or a patient. In Connecticut, the current EMS rate-setting regulations rarely allow service providers to recover the actual cost of their services, due to mandatory write-offs predominantly associated with government payers (Medicare and Medicaid). Additionally, there is no reimbursement mechanism for services not associated with providing patient care or transporting a patient to a care facility. The cost of readiness is largely overlooked.
I believe the answer to this is not a one size fits all for every community. For municipalities, there must be financial support for the public safety services provided by EMS agencies. For the work of providing care and transport to patients, if this is going to continue to be funded through a fee for service model that allows different payers to pay different amounts for the same service, then it must be acknowledged that different communities have vastly different payer mixes. This means that two communities with the same number of billable patient interactions may have very different reimbursement rates for the same work. It isn’t fair to ask insurers in one community to pay more for the same service than they do in a different community, however it is equally unfair to ask EMS services in less affluent communities to provide the same service with less funding because the government payers don’t reimburse for the actual cost of the service that their beneficiaries receive. This EMS reimbursement model unintentionally has a negative impact on services in poorer areas and needs to be addressed as a part of an overall EMS funding reform plan.
There are certainly other challenges facing the EMS industry, however I believe that the most critical are those mentioned here related to workforce stabilization and funding for services. Addressing these requires cooperation and commitment from every corner of our industry. Solutions will come from prioritizing what is in the best interest of the communities we serve and of our people providing the service. As an EMS leader and system advocate in Connecticut I am committed to working toward solutions to these challenges. As an EMS system stakeholder, I hope you see value in doing the same.