how y'all doin'?

this is a follow-up to a previous post dated december 16th regarding the plight of an important segment of the health care profession. two readers expressed concern. one asked what they could do to help.

for Chris and Betsy in particular, and for anyone else so inclined, Anne has responded with an article specifying some of the professional concerns of the EMT/EMS community and what you can do to help.

(the original formatting was lost in my cut and paste. all emphasis in what follows the cut is mine.)

as anne says, "it's long." (that's an understatement! hahahaha.)

but i ask you again, what if *you* weren't there to care for your loved ones? who's gonna go the extra mile for them when they need it most?


Wednesday, December 19, 2007

This is a long one......

I have been asked on more than one front to explain my last blog and so I shall. I will attempt to use a bit of brevity here, but if you know me, you also know that is a difficult thing for me to do. In order to understand where we are now in this profession, it is important that you understand where we have been and why today's issues exist. For those of you in the field, please bear with me as I try to explain to those who are not.


The 'ambulance drivers' as you know them today, did not begin as a profession until the 1970's. Prior to that, a person took their chances on funeral home services, the civil defense squads and just plain driving fast to a hospital. The hospitals were also ill equipped to handle emergencies as the doctors did not stay at the facility 24 hours a day. Even in the early part of my own career, doctors had to be summoned from home to respond to the emergency room (yes, a true 'room' as only one existed then). The doors were kept locked and it required someone phoning in, in most cases, to assure that the doors would be open upon our arrival.


The first people to work on ambulances did not necessarily have to be EMT certified, and paramedics were non-existent until the late 1970s. Even though the TV show Emergency was on the air waves in the early and mid-70's, paramedics were only found in large metropolitan areas, with most of them linked to the Fire Services. This is an important factor for part of the problems that we face today.


In 1973 the Emergency Medical Services Act dictated that all states in America develop an EMS system to respond to its citizen's needs. A template was developed by the Department of Transportation which gave direction for this federal law. Interesting to note that we are still regulated, federally, by the DOT. To make sure that compliance would be met, every state was given grant money to assure that the systems would be developed. This is another issue that came back to bite us in the butt later when the grants were eliminated.


I feel a need to explain the different levels of service that an ambulance crew provides when they are summoned as this is another area that most people do not understand. For the general public, we are all labeled as 'EMTs' and for those of us who have trained vigorously as paramedics, it is a near insult to be called such. Not that we feel that EMTs are less important, less efficient, or even less deserving of recognition, but it is equivalent to calling a Registered Nurse a Certified Nursing Assistant after all the long hours of training and responsibility that goes into the career. All nurses are not equal any more than all ambulance personnel are equal. There is a saying in our field that paramedics save people, EMTs save paramedics and that is very true. We could not exist without their expertise any more than a doctor can work independently of his nursing staff.


EMTs are trained to do more than drive, (please stop calling us ambulance drivers) and in this state they have the ability to start IVs, give some medications, and handle trauma patients nearly to the same capacity as the paramedic. Training here takes 14 weeks of intense 40-hour work weeks, or if they elect to be trained in a formal educational setting such as a technical college, they commit a full year of class work on a part-time basis.


To become a paramedic, you must already be certified as an EMT and in some cases, have experience under your belt to enroll. It is a full-time program no matter where the training takes place and with much cramming, it can be done in one year. To become a paramedic, it is a minimum of two years of training when you include the EMT level. As much time as it does to become a nurse. Starting pay for the average EMT is $8/hr., the paramedic, $10/hr. Nurses make up to $25/hr. to start. And let me add, that they generally work 40/hr work weeks and the average EMS person works 72+ hrs/week if they are lucky enough to have family to contribute to the income. Otherwise, they all work a second job and the hours can be in excess of 120/week. Even after nearly 27 years of service, I must work a second job to make ends meet. Think about that when you see an ambulance driving down the road at 3:00 in the morning and realize the person driving may be in their 48th hour of working straight, with little down time.


Paramedics can do everything, let me repeat that, everything that can be done in an emergency department in an acute emergency. They only things that they cannot do are the many diagnostic tests (blood work, X-rays) and the stabilization of injuries such as suturing cuts and casting broken bones. (In some states, they are even doing that) Our patches for such things are only temporary.


What is amazing about this field is that we are able to come to the same conclusions in most cases, treat with the same drugs and electricity, and tend to the general health and well-being of anyone, with any condition, all without the benefit of those diagnostics that are available in the ED. Most of these conclusions and treatments are done within literally, seconds. We train them to use all of their senses, see what is not there, and then react even before most people even realize that a problem exists. We do have some diagnostic equipment available and the speed at which more and more is available to us every year is astonishing. This alone elevates the costs of running an ambulance service tremendously. A cardiac monitoring machine costs somewhere in the area of $15,000, so you see how difficult it is to equip ourselves with the best tools that are available to us. We spend the dollars where it can do the most good for all.



Herein lays the problem. We are broke. We cannot continue to provide services with the resources that we are allotted. Now, before you decide to run off to another page because you feel I am merely whining about a money issue, let me give you some facts that may surprise you and may affect you personally.

We are mandated by law to respond to every emergency. This is not an option if you are a 911 service. Regardless of your ability to pay. We are also not able to pick and choose who we may treat and transport. "You call, we haul" is a saying in this field that is not a derogatory statement, but a fact. We are not able to say no, even if they are complaining of something as ridiculous as a hangnail. If you go to a doctor's office, he can elect to not treat you if you are not able to guarantee payment. A hospital must look at you in the emergency department, but they are not required to admit you, if you cannot pay. Many people call us not because they need to be in an emergency room, but because they need a ride across town and they know we do not ask for payment at time of service. I have had patients who were seen standing out on the street corner drinking a bottle of liquor from the local liquor store before I was even able to complete my paperwork at the hospital. They wave as we drive by. You call 911, we come.



Here are some hard facts:

Average cost for EACH ambulance transport is $415. This is factored by looking at costs to include fuel (almost all are diesels), salaries, mechanical wear and tear, insurance, equipment, etc.

70% of our patients are Medicare or Medicaid recipients, 25% are private insurance payees and 5% are self-pay.

In order for us to be reimbursed the patient must be suffering from an illness or injury which contradicts transportation by any other means.

If they can sit up, an ambulance is not required in most cases and payment is not made. We cannot bill the patient directly if they are not eligible for transport.

All medically necessary services, supplies and procedures are included in the base rate. We cannot bill for anything other than the transport.

Reimbursement is determined by zip code at point of pick up, not type of call, or services rendered.

Mileage can be billed, but only from point of pick up to closest appropriate facility. If the patient requests to go to a facility that is not closest, we are mandated by law to transport them there. We receive no mileage reimbursements for the overages. Medicaid will not pay for mileage until after an initial 10 miles have been driven.

Medicare only pays 80% of ambulance reimbursements after the patient has met their deductible ($131 for 2007). Here's an example:



Average Ambulance charge- $525.00

Allowable charges from Medicare- $330.89

Medicare reimbursement (80%) $264.69

Patient's responsibility- $66.20


Average collection rate for most ambulance services is at 40%. We will only see $26.48 from the patient. That means total collection is $357.37 for a $415. transportation expense. If transportation was denied by Medicare, we receive nothing and we cannot bill the patient.

Much Federal aid became available to emergency services after 9-11 and Katrina. Many of the grants available were focused on the obvious need for more training and equipment to handle terrorism and domestic preparedness. Not for operating costs to run a department. VERY LITTLE grant money was given to EMS alone. The EMS services that benefited were governmental or fire department based services, which brings me back to the origin of paramedical services. They were fire-based and therefore it is assumed that all EMS systems are still integrated with the fire departments. EMS services are the step-children in public safety and get very little in the way of aid. Some local governments give subsidies to their ambulance service to help defray costs, but average amount is about $200,000/yr. When most services put 200,000 miles or more on their units a year, look at the costs of fuel alone. How much did it take to fill up your gas guzzler at the gas tank? We probably average 10-15/mile per gallon with our units.


We are dying in this profession because we are no longer able to compete with the other healthcare fields. When salaries are so low, for twice as many hours and too oftentimes we are lucky to even put our head on the pillow, let alone eat, it is not surprising that the numbers are not there for people coming into this career. The technical colleges average a dozen paramedic students a year. In this state, only 38% of the paramedics who start a program are eventually licensed. We lost 81 paramedics last year alone due to death or retirement. The average age of an EMT is 43. For the paramedic, it is 40. Who will be left a few years down the road? We are literally, dying off, closing down and just plain going out of business. Many a day, I have purchased supplies out of my own pocket just to have what I needed to treat a patient. We have given until we can't give any more. We are desperately in need of help if there is any hope of remaining true to our commitments.


Here's what you can do. If you are in EMS, please call the politicians in your area and let them know what is happening. The ones we talked to at the senate hearings were shocked to learn of what our profession has become. They advised that they were not aware of the issues, and no one has approached them with any concerns, let alone any resolutions. Legislation is being drafted in this state to relocated monies to the EMS state offices to help us in becoming more financially secure, and try to make grant money available. Support the bills, call the legislators. If they hear from enough of us, they will act if only to shut us up. Go to www.ga-ems.com and read what is happening and what is being proposed.


If you are in the private sector, please support legislative changes in Medicare and Medicaid reimbursements. At least help us to break even. Call your legislators as well. Find out the condition of the ambulance service in your area. Raise funds. Buy much needed equipment. Some services rely totally on donations. See how your system is financed. Do not wait until a disaster to recognize that we exist and then praise our accomplishments. You have no idea how many people die annually in this field. We don't speak of it outside of inner circles, as it is not in our nature to let others know of our pain. Do a google search on LODD (line of duty deaths) and look at the numbers. Please don't pretend we don't exist until you call 911 and want us to work a miracle with units that are falling apart and equipment that may not work.


I, too, have kept quiet about our issues because our field was built on the concepts that if you can't play with the big dogs, stay on the porch. Suck it up. Make do with what you have. But I am now afraid. Afraid, when I see the numbers gradually dwindling in this wonderful profession because we don't have the resources or the attractions to bring in another generation, that we are truly dying a slow death. Help me make one last positive change for the people that I love and the career which has kept me sane for so many years. Our healthcare system is broken. Help us fix it.