Report: Workers, higher reimbursements needed to stabilize EMS
May 9—With emergency medical technicians rapidly leaving the field and family-owned ambulance services shutting down, New Hampshire is struggling with a state of emergency in ambulance services, according to a report released Tuesday.
Last week, DiLuzio Ambulance in Keene announced it would cease operations. The closing caused other services in the Monadnock region to cover both its primary and secondary services. The fledgling Cheshire County EMS, which launched at the end of last year, put a fifth ambulance into service in response.
The New Hampshire Ambulance Association commissioned the report in hopes of "swift legislative action to prevent more service closures, including money included in the two-year state budget to increase Medicaid reimbursement rates."
The association represents both municipal and private ambulance services.
The 32-page report highlights the industry's challenges, such as insurance reimbursement rates and workforce retention. The goal was to provide a starting point for discussions about what the state can do to improve the situation, said Justin Van Etten, executive director of the association and executive chairman of Meredith-based Stewart's Ambulance Service.
Emergency 911 services are mostly in good shape because of taxpayer subsidies, but transports between medical facilities present a larger challenge, Van Etten said.
"EMS stakeholders interviewed do not believe New Hampshire will get to the point where 911 calls go unanswered, but they do believe residents will experience slower and delayed response times that can impact patient outcomes," the report reads.
Sen. Suzanne Prentiss, D-Lebanon, knows the issue well. She works as a paramedic and previously was chief of EMS at the state Department of Safety.
"This is something I've been thinking about and worrying about for a long time," she said. "I don't think this is just a rural issue anymore. There is some urban and suburban nature to this now as well. We have to take that seriously."
Last summer, Prentiss worked with Safety Commissioner Robert Quinn to appoint a task force on workforce development and retention.
"It is one thing to know, 'Are we going to have people to answer ambulance calls?'" Prentiss said. "But moving patients between hospital or health care facilities is really important to the entire health care system. That area raises a red flag for me."
The reimbursement
The study says the root problem is inadequate reimbursements from Medicaid, Medicare and insurance companies. Ambulance companies also can't charge unless the patient is transported.
Some agencies are being paid less than they did a decade ago, despite rising fuel and labor costs, Van Etten said.
For example, insurance reimbursement can range from $400 to $4,000.
"We either have to accept what they give us or have to go and charge (the patient) the difference," he said.
Changes in demographics can create challenges, especially for communities with higher populations of low-income and elderly residents.
The report contains an example from the Derry Fire Department of the disparity between actual costs and reimbursement rates.
The town received an average of 37% of its billable rates from Medicare and 14% of its billable rates from Medicaid, according to the report.
Prentiss said multiple proposals are in the works in the Legislature to address reimbursements.
"This is just one of the ways that we can help to lessen the prices and shore up the system," she said. "We have to improve reimbursements."
Challenges are expected to increase as the state's population continues to age.
Consolidation of services by hospital systems also is prompting an increase in demand for medical transportation, Van Etten said.
Worker shortage
Many emergency medical technicians, who are typically paid $15 per hour, are leaving for similar roles in triage in hospitals and other health care providers, which have higher hourly rates. Some leave for higher-paying positions in other industries.
Nationally, the turnover rate is 36% for full-time emergency medical technicians and 27% for full-time paramedics, according to the report.
In January, 45th Parallel EMS implemented its largest raises ever in an effort to keep up with inflation and retain staff, according to Nathan Borland, head of one of the biggest nonprofit EMS agencies in New Hampshire.
Van Etten's Stewart's Ambulance Service became employee-owned to offer more benefits to the workers.
Of the 40,000 workers needed nationally between 2016 and 2030, New Hampshire could use about 1,000, Van Etten said.
The solutions aren't simple.
Last year, a commission in Maine recommended the state spend $350 million over years to quell the crisis in that state, according to the report. Other states also have done extensive studies on how to overhaul the system.
A longer-term solution includes putting more pressure on insurance companies to pay a "reasonable rate" of reimbursement, Van Etten said.
"They can't pay below cost and expect services to continue to be provided," he said.
In the meantime, Van Etten hopes an increase in Medicaid reimbursement is approved by the Legislature.
"That is an absolute necessity if we want to see EMS services survive in our lower-income communities in New Hampshire," Van Etten said. "We are hopeful by demonstrating the crisis that's occurring, the Legislature and the governor will continue to include this increase in Medicaid reimbursement rates."
If all else fails, Prentiss plans to file an amendment in the budget for higher reimbursements. The plan is to get the Medicaid reimbursement equal to Medicare.
"We don't want to wait until this is really bad," she said. "Now we have some proof that there is a problem."
