Milwaukee's emergency medical services system needs more than Band-Aids to prevent disaster
As ambulance staff in the UK strike, most callers to the 999-emergency system (the equivalent of 911) could expect to wait hours before an ambulance arrives. This might sound unfathomable in the United States, but it’s not. While working as an EMT, or an emergency medical technician, for a private ambulance system in Milwaukee, I saw an emergency medical system, or EMS, in crisis and on its way to disaster.
The Milwaukee Fire Department has only 12 advanced life support (ALS) ambulances. A single major emergency, like a serious car crash or shooting can soak up a big chunk of these resources. This can leave sections of the city without ambulances to transport patients. To address this shortage, Milwaukee implemented an uncommon fusion of public and private services where private ambulances staffed with EMTs transport less seriously ill patients (basic life support, BLS). This preserves the advanced paramedic ambulances for the most serious calls. I worked for one of these private ambulance companies for a year and saw that this precarious arrangement is in crisis.
The locally owned and operated private ambulance companies participate in this “911 contract” because they feel a sense of service and obligation to the community, not because it is highly profitable. Pre-scheduled private transports between facilities are the bulk of the business and are generally reimbursed better than transports from 911 calls. When two of the four private ambulance companies left the 911 contract in recent years, it left the busy Northwest Side without any basic ambulance coverage. Fire engines waited on the scene of an emergency for private transport for up to an hour, and on the private ambulances, we would drive up to 30 minutes from the nearest stations to reach scenes.
In an attempt to get the remaining private companies to prioritize 911 calls, the city allocated $4.7 million in September 2021 to fund larger bonuses, $60 to $80, per transport, as well as to temporarily operate two public basic service ambulances. The fire department also agreed to a temporary cross-staffed ambulance arrangement, where a Milwaukee firefighter would drive a private ambulance crewed by one private employee, and the ambulances would be assigned to the northwest service area. The plan was designed to give the private companies time and resources to recruit enough EMTs to cover the service area alone.
This Band-Aid solution, while critical, will not solve our ambulance shortage because the driving factors are more systemic. Increasing privatization and public budget cuts combined with a growing demand for EMS services are spreading resources thin nationwide. Nine months after the emergency funding, a policy change doubled the allowed response time for BLS ambulances from 30 minutes to an hour. The nation’s EMS system needs creative, proactive solutions that focus both on reducing demand on the 911 system and increasing supply of EMTs.
Ambulances can only transport patients to a hospital emergency department, not to urgent cares or clinics, but new technologies and systems can help triage care and destinations more appropriately. One study used a telehealth system to connect callers to an emergency physician. EMS initiated contact with a physician who triaged care and, if appropriate, connected patients to a pre-paid ambulance alternative to transport them to a clinic or, if needed, an emergency room. With fewer non-urgent transports, ambulance crews finished calls an average of 44 minutes faster, and the cost savings were estimated at nearly one million dollars. Examples of ambulance alternatives include Uber Health and Lyft Concierge, and these could complement survey findings that most people who unnecessarily take an ambulance do so because they cannot access an alternative form of transportation. Greater choice for citizens in price and destination could also improve continuity and quality of care.
A robust EMT supply requires strong recruitment and retention efforts. I remember driving in the ambulance and seeing that a local custard shop was hiring at the same starting wage that I was making. Low pay drives rapid employee turnover, and the legislation to increase insurance reimbursement is not keeping up. Compensation must reflect the education and dedication that EMS workers commit to their communities, and local governments should support or lead the efforts to increase public insurance reimbursement for high-value (appropriate) ambulance transports. Additionally, local departments and private companies should create and continue investing in pipeline programs for a long-term EMS workforce, such as cadet programs.
In Milwaukee and across the country, EMS systems face an increasingly dire burden, and we are paying with our wallets and our health. It’s time for local governments to commit to long-term solutions. Starting the hard work now will ensure that community members who experience or witness a medical emergency can trust that help is on the way and that it will be there soon.
David Deshpande is a Milwaukee native, UW–Milwaukee graduate, and first-year medical student at the University of Chicago Pritzker School of Medicine.
This article originally appeared on Milwaukee Journal Sentinel: Ambulance services in Milwaukee needs long-term fixes to avert crisis.
