'Forced to do more with less.' How the complexities of the EMS business affects response times

Note: This story has been updated to correct a misattributed quote and to clarify information regarding Medicaid.

Ask the leader of Chatham County's EMS provider about the challenges his organization faces in responding quickly to medical emergencies, and he'll use a health care term familiar to the public.

Triage.

Chatham Emergency Services is the privately held nonprofit that, under state law, is the county's exclusive ambulance service. The EMS provider's slowing response times ― an average of 15 minutes for life-threatening emergencies ― has prompted concerns from local government officials and support for reform measures introduced earlier this year in the Georgia General Assembly.

Blame for the delays is shared between Chatham Emergency Services, Chatham County's 911 center and local hospitals operated by Memorial Health and St. Joseph's/Candler. Chatham Emergency Services CEO Chuck Kearns, himself a trained paramedic, is working with colleagues in those organizations to triage those challenges.

Yet Kearns acknowledges the shortcomings in his agency ― and how difficult many of these weaknesses are to resolve.

Here’s a look at Chatham Emergency Services and the issues plaguing the provider.

Why is Chatham Emergency Services the county’s lone provider?

State law dictates how emergency management services are run. From the highest level, the Georgia Department of Public Health oversees the state’s 10 different EMS regions, with Chatham County being in Region 9. Each region is then further broken down into territories or service zones where ambulance services are provided.

Zones are delineated based on how effectively the EMS provider can serve residents ― by need rather than municipal lines. The zoning regulations prevent cities from officially contracting or creating their own EMS agencies.

In Chatham County, there are four EMS zones: Zones 1 and 2 encompass the Savannah city limits, while Zone 3 covers West Chatham, including the cities of Bloomingdale, Pooler, Garden City and Port Wentworth, and the Zone 4 service area covers Thunderbolt and the islands, including Tybee.

Prior to 1997, three independent ambulance companies operated in the county. Chatham Emergency Services, then known as Southside Fire, serviced the regions outside the Savannah city limits while two other EMS providers serviced the in-town areas.

Chatham Emergency Services grew its coverage area by purchasing Mercy Ambulance Service from St. Joseph/Candler in 1997. Fourteen years later, Chatham Emergency Services became the county's lone EMS provider by buying MedStar One Ambulance.

Those acquisitions meant a greater financial strain on Chatham Emergency Services. Neither Mercy nor Medstar were directly subsidized by taxpayers, and Chatham Emergency Services negotiated a contract with Chatham County that provide only enough funding to operate one ambulance, approximately $600,000.

So how is Chatham Emergency Services funded then?

Chatham Emergency Services is funded predominantly by patients it has transported to the hospital and their insurers. The EMS provider bills Medicare, Medicaid and private insurers, a framework that is falling short of what the ambulance service needs, according to the Kearns.

Medicare is the primary payer for ambulance services and contributes close to 50% of Chatham Emergency Services' revenue. Medicaid, which provides heath care insurance for low-income Georgians, senior citizens, children and those with disabilities, hasn't adjusted its rate, other than for inflation, since 2006.

As for private insurance companies, billing processes vary. Many insurance plans have high co-pays and deductibles, meaning Chatham Emergency Services must bill patients directly.

Kearns calls the situation usurious, noting that five different private insurers have collection balances of more than $1.5 million.

“Commercial insurance companies do the best that they can to keep their money in their pocket,” Kearns said. “That is a huge amount of money for a small, one county agency like ours.”

Meanwhile, the $600,000 yearly stipend of county taxpayer money “doesn’t even come close to paying for one ambulance a year,” said Kearns. “And they’re (county) trying to drive it to zero, when it needs to go the other way.”

Prior to the COVID-19 outbreak, Chatham County's long-term goal was to end the ambulance subsidy. As part of Chatham Emergency Service’s 2011 contract with the county, the EMS provider was to submit a feasibility study on how to zero out the subsidy. However, since the pandemic, medical emergencies and other ambulance needs have soared.

County officials recognized the problem and have aided Chatham Emergency Services in applying for grants and recruiting new EMTs and staff. But more needs to be done at higher levels, said Kearns.

When ambulance transfers and hospitalizations peaked in most communities during the pandemic, EMS services didn’t receive federal or state stimulus funding.

While ambulance service is a vital cog in the public health and first responder system, EMS is often overlooked, explained Phil Koster, CES Chief Operations Officer.

“The reality is this: folks want service, but they don’t want to pay for it,” Koster said.

How do funding constraints affect personnel?

The chokehold on funding directly affects salaries and employee retention in the industry. For years, salaries for EMTs and paramedics have stagnated while the need for care has ballooned.

Between 2019 and 2022, the number of 911 calls increased by about 6,000, a majority of which are attributed to nuisance or “good intent” calls, or incidents that don’t require ambulance transport or immediate medical attention. Yet, an ambulance is still dispatched to the scene.

At the same time, the total number of Chatham Emergency Services staff declined. Between 2020 to 2023, the number of paramedics and EMTs decreased from 147 to 125. Full-time EMTs trained in basic life saving measures and full-time paramedics trained in advanced life saving measures are either switching to part time work or leaving the field entirely.

Chatham Emergency Services has seen recent staffing gains, with four full-time paramedics and 10 full-time EMTs joining the agency since the end of January. Still, Kearns said the organization remains understaffed

“EMS is truly being forced to do more with less,” said Kearns.

The trend isn’t unique to just Chatham County.

“It doesn’t matter if it’s a small county that’s rural or a large area like Chatham County, the challenge is there’s a shortage of paramedics, EMTs and personnel willing to work anymore,” said Georgia’s EMS Region 9 director, Robert Shad. “They’re being burned out across the state and nationwide and finding other things to do that make a lot more money with a lot less hours.”

In Chatham County, a full-time EMT earns between $53,910 and $59,301. A full-time paramedic earns between $71,244 and $78,368. Compare that to the Savannah area's average salary of $57,616.

With the buildout of the Hyundai EV plant and the opening of several auto part supplier facilities looming, Chatham Emergency Services' Koster and Kearns fear competition for labor is only going to increase.

What are Chatham Emergency Services' resources?

Chatham Emergency Services has a total of 46 ambulances in service and another two on order, making it the largest EMS provider in Georgia’s Region 9 and one of the largest in the state.

During peak times, Chatham Emergency Services has around 25 ambulances on call for the 911 system. Each ambulance typically staffs either two EMTs or one paramedic and one EMT. About 5% of 911 calls require paramedic skills, according to Koster.

In addition to ambulances, Chatham Emergency Services can deploy eight Quick Response Vehicles (QRVs) with a single paramedic. QRVs are smaller vehicles that are dispatched for higher priority emergencies.

The ambulances are staged at 32 different locations throughout Chatham County’s 630 square miles.

How busy is Chatham Emergency Services?

By law, Chatham Emergency Services must respond to all requests for assistance. In 2022, that number averaged 162 calls a day, or nearly 60,000 for the year. Of those, only 46% required transport to the hospital.

According to Chatham Emergency Services' Kearns, calls range from those made by homeless individuals seeking food and shelter to parents overwhelmed by a child's discipline issues. The ambulance service used to offer transport assistance as a side business but ended that practice in recent years due to the overwhelming demand for EMS.

“If we rewind the clock back 40 years, ambulances were called if you had a pitchfork sticking out of you, or a car accident, or you were stuck in a tree,” said Phil Koster, Chatham Emergency Services' chief operating officer. “Today, I've got this rash that I've had for six weeks. Mom needs help off the toilet. We had one earlier this week of a mother saying my child's not listening to me.”

This article originally appeared on Savannah Morning News: Chatham Emergency Services struggles speak to EMS ambulance challenges