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Recruitment, Retention & Reimbursement (RR&R)Issues in EMS
I would like to start a discussion on RR&R so that we may share info., ideas etc. on this growing problem which is killing EMS. Many services have gone out of business and our numbers are dwindling.
How can such a "vital" public service be disregarded by our elected officials? How can we (the hometown Army, who responds to every conceivable type of public emergency)survive and become healthy again?
The answer lies in the third "R" of RR&R and thats Reimbursements.
According to the FEMA report, approx. 85% of R&R programs require money for incentives to address the problems we face in Recruitment & Retention. Since the 2007 Fed. GAO report states that Medicare only pays 6% below "cost to operate", that leaves us in a deficit for every MC call we take. BTW, the GAO report also states that on average all across the US, Medicare runs are 40% of total ambulance runs in the United States. I'm sure there are EMS agencies that have more or less than the national average of 40%, but that fact is staggering. 40% of our business (paid for by the US Govt) is "below cost to operate". In Pa., Medical Assistance only pays $120. for a (BLS) Emergency call (approx. half of what MC pays). I don't have the exact stats. but have heard that Med. Assist. runs account for anywhere between 15% to 75% of an EMS agencies call volume in Pa. To add to our existing problems of hemorrhaging cash, Pa. law bases reimbursements for vehicle accidents and workman's comp. calls on the established Federal MC rates. Currently under PA law, we are only allowed to make approx. 7% above "cost to operate" for MVAs and 4% above "cost to operate" for Work. Comp. calls.
Adding all this together, it is safe to assume that approx. 75% or more of our call volumes are reimbursed at a substandard level. How can any business survive on such paltry reimbursements? Did I forget to mention the other percentage of calls we take where the patients gets the money from their insurance company and doesn't send it to EMS? And what about the volume of calls we take where the patient can't afford insurance but makes a little too much for Med. Assistance. These end up being writeoffs.
Since EMS in rural America is usually a stepchild of a fire dept. or other agency, what effect is substandard EMS reimbursements having on the parent organization? My take is that EMS is burning up "parental resources" of vol. fire depts. etc. and eating up their assets. I wish more depts. would do actual audits to prove this out. Its like Joe (from the fire dept.) is trying to save Jim (EMS) from drowning. The more effort Joe puts forth to try to save Jim just compounds the problem. If something new and different doesn't happen soon, Joe fireman and Jim EMS are both going to drown. The typical case of the rescuer drowning with the victim. EMS & Fire need some mutual aid from our governments.
The facts and answers are all too clear. EMS doesn't get enough money to survive. The Federal and state governments "control" EMS reimbursements and do not allow us enough money to survive on, much less save up for replacement equipment, vehicles, incentives for volunteers or salaried staff. The problem is lack of money and the source of the problem is our government's low reimbursement for our life saving services. How many businesses do you know of that the government controls (and puts limits on) how much money you can make?
The solution to the problem is "HOW" (to quote the Boeing tv commercial)
HOW do we fix this to avoid the inevitable "Crash of EMS" in our country? HOW do we continue to provide our daily EMS services, much less provide mandated Homeland Defense services for our citizens? Here's another interesting fact. Currently, EMS only gets approx. 4% of Federal Homeland Security "First Responder" funding. Further, hospital based EMS services (and those associated with hosp. base EMS) do not qualify at all for Federal First Responder grants.This leads me to ask the question. If EMS can barely survive on a daily basis today, how in the world are we expected to mitigate a pandemic, terrorist attack or any other extraordinary mass casualty event that may occur? How safe are we and how safe is the public who depend on us? Thats a scary thought.
I would invite anyone interested in EMS to participate in this discussion. Please focus on the "HOW" we can save EMS from deteriorating any further and "HOW" we can make positive changes for the future. I will share the work of "HOW" we are addressing the problem here in Lycoming County, Pa. through our RR&R Committee of the Lycoming County EMS Council in later posts.
Looking forward to your comments. John W. Magyar
How can such a "vital" public service be disregarded by our elected officials? How can we (the hometown Army, who responds to every conceivable type of public emergency)survive and become healthy again?
The answer lies in the third "R" of RR&R and thats Reimbursements.
According to the FEMA report, approx. 85% of R&R programs require money for incentives to address the problems we face in Recruitment & Retention. Since the 2007 Fed. GAO report states that Medicare only pays 6% below "cost to operate", that leaves us in a deficit for every MC call we take. BTW, the GAO report also states that on average all across the US, Medicare runs are 40% of total ambulance runs in the United States. I'm sure there are EMS agencies that have more or less than the national average of 40%, but that fact is staggering. 40% of our business (paid for by the US Govt) is "below cost to operate". In Pa., Medical Assistance only pays $120. for a (BLS) Emergency call (approx. half of what MC pays). I don't have the exact stats. but have heard that Med. Assist. runs account for anywhere between 15% to 75% of an EMS agencies call volume in Pa. To add to our existing problems of hemorrhaging cash, Pa. law bases reimbursements for vehicle accidents and workman's comp. calls on the established Federal MC rates. Currently under PA law, we are only allowed to make approx. 7% above "cost to operate" for MVAs and 4% above "cost to operate" for Work. Comp. calls.
Adding all this together, it is safe to assume that approx. 75% or more of our call volumes are reimbursed at a substandard level. How can any business survive on such paltry reimbursements? Did I forget to mention the other percentage of calls we take where the patients gets the money from their insurance company and doesn't send it to EMS? And what about the volume of calls we take where the patient can't afford insurance but makes a little too much for Med. Assistance. These end up being writeoffs.
Since EMS in rural America is usually a stepchild of a fire dept. or other agency, what effect is substandard EMS reimbursements having on the parent organization? My take is that EMS is burning up "parental resources" of vol. fire depts. etc. and eating up their assets. I wish more depts. would do actual audits to prove this out. Its like Joe (from the fire dept.) is trying to save Jim (EMS) from drowning. The more effort Joe puts forth to try to save Jim just compounds the problem. If something new and different doesn't happen soon, Joe fireman and Jim EMS are both going to drown. The typical case of the rescuer drowning with the victim. EMS & Fire need some mutual aid from our governments.
The facts and answers are all too clear. EMS doesn't get enough money to survive. The Federal and state governments "control" EMS reimbursements and do not allow us enough money to survive on, much less save up for replacement equipment, vehicles, incentives for volunteers or salaried staff. The problem is lack of money and the source of the problem is our government's low reimbursement for our life saving services. How many businesses do you know of that the government controls (and puts limits on) how much money you can make?
The solution to the problem is "HOW" (to quote the Boeing tv commercial)
HOW do we fix this to avoid the inevitable "Crash of EMS" in our country? HOW do we continue to provide our daily EMS services, much less provide mandated Homeland Defense services for our citizens? Here's another interesting fact. Currently, EMS only gets approx. 4% of Federal Homeland Security "First Responder" funding. Further, hospital based EMS services (and those associated with hosp. base EMS) do not qualify at all for Federal First Responder grants.This leads me to ask the question. If EMS can barely survive on a daily basis today, how in the world are we expected to mitigate a pandemic, terrorist attack or any other extraordinary mass casualty event that may occur? How safe are we and how safe is the public who depend on us? Thats a scary thought.
I would invite anyone interested in EMS to participate in this discussion. Please focus on the "HOW" we can save EMS from deteriorating any further and "HOW" we can make positive changes for the future. I will share the work of "HOW" we are addressing the problem here in Lycoming County, Pa. through our RR&R Committee of the Lycoming County EMS Council in later posts.
Looking forward to your comments. John W. Magyar
Replies to This Discussion
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Permalink Reply by ArcticKat on -
Fortuantely the provincial government in Saskatchewan has had the foresight to actually address this issue.
http://www.healthcareersinsask.ca/Careers/llcu/incentives.html
I have take advantage of some of the grants already.
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Permalink Reply by John W. Magyar on -
ArcticKat said:Fortuantely the provincial government in Saskatchewan has had the foresight to actually address this issue.
http://www.healthcareersinsask.ca/Careers/llcu/incentives.html
I have take advantage of some of the grants already.
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Permalink Reply by John W. Magyar on
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Thanks for the info. and the link. Back in 1976 when I was Pres. of Am. Assn. of Trauma Specialists, I traveled to Calgary for the first Interphase Conference. I did a ride along for about 12 hours and came back to the states thinking how well the Canadians had their EMS act together. I remember the ambulance we rode in was a lowtop Type ll van with a medic and an EMT as the crew. The oxygen, suction and other equipment was not duplicated by having onboard and portable; it was all portable. After we delivered the pt. to the ER, a quick report was given,supplies were replaced and we were back on the road again to handle more calls. I couldn't help thinking how much of a common sense approach this was and how much more reasonable the cost must have been compared to our EMS systems in the states. Today, 32 yrs later, EMS has so many costly governmental regulations and we wonder why we're in trouble.
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Permalink Reply by Robert B on -
Part of the issue stems from the very transparency of what we do in the eyes of the general public. EMS is a 'utility' much like any other in their eyes, and one which only needs to be paid for when used. Since most people use our services infrequently (until perhaps their later years), it is out of sight and out of mind. EMS needs to have a concerted PR effort to raise general public awareness of exactly HOW the service that they take so for granted is currently (barely) provided. However, since EMS as an industry has no real central governing body, standards or agency to be the standard bearer (and budgeter) of this type of effort, it's unlikely to happen. Until such time as EMS is really brought together nationally under one organization, it's hard to get the necessary lobbying power, budget or 'marketing' effort into place (not to mention the ridiculously fractured and inane licensure and certification process).
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Permalink Reply by John W. Magyar on
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About 6 mos. ago I brought up the problems of RR&R at our county EMS Council mtg. I asked for a committee to be formed to study these issues and thats where the fun began. We had many mtgs to discuss all the causes of our problems with Recruitment and Retention and finally determined that we couldn't do much without factoring in Reimbursement (or lack thereof) According to the FEMA manual on R&R, about 85% of the plans to fix R&R required money. We decided to add Reimbursement to the equation. After much research, we determined that Reimbursement was key to our R&R efforts and the survival of EMS in general.
Since there is little we can do to affect Federal Medicare Reimbursement locally, we decided on the following:
1. Support the efforts of Advocates for EMS and American Ambulance Assn. in increasing MC fees
2. Contact our local Federal elected officials and ask them to join the EMS Caucus
3. Provide an EMS Legislative Workshop for all Fed. State and local elected officials for awareness of the financial hardships that EMS agencies are currently experiencing
For higher reimbursements in Pennsylvania, we decided on the following:
1. Support the efforts of the Ambulance Assn. of Pa. in getting Medical Assistance Fees raised to an acceptable level
2. Request our state officials become involved with and support the efforts of the Pa. Emergency Services Legislative Alliance http://capwiz.com/pfesi/home/
3. Work to revise Acts 6 and 44. These Acts base reimbursements for MVAs and Workman's Comp. calls on Federal MC
fee schedule.
4. Invite the state officials to our EMS legislative workshop to promote awareness of our serious financial EMS crisis.
For our local county borough and township officials:
1, Invite them to our EMS Legislative Workshop to promote awareness, since they are legally responsible now for EMS.
2. Urge local elected officials to get involved with their local EMS agencies and understand their operation and problems.
3. Urge local officials to join and support PESLA
We hope that Phase 1 (Awareness via our workshop) will lead to Phase 2 (which will launch an EMS Task Force and bring together all stakeholders to study our current RR&R problems). Phase 3 would be the implementation of any action plans the Task Force would develop to deal with our EMS RR&R problems.
Its high time that the public, governmental officials and others concerned with EMS step up to the plate and give us a hand.
EMS manpower is dwindling to a dangerous level. The younger generation doesn't want to work for paltry wages and they certainly don't want to do it for free as volunteers, especially when there are no incentives for them to take all the training etc. When Garbage collectors make more money than EMT & Paramedics (who save lives and risk their own safety and health), something is really wrong. Check out the Federal Dept. of Labor and compare the wages of an EMT/Medic to that of the garbage man.
Till next time, Be Safe out there. John
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Permalink Reply by John W. Magyar on
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Due to several requests from members of our group, I have decided to move this discussion to the Pa. EMS Providers Group.
I would like to invite ALL members from all states/provinces/countries of JEMS Connect to come to our Group site to participate in this discussion.
http://connect.jems.com/group/pennsylvaniaemsproviders
We welcome all positive comments and thank you for your participation. John W. Magyar
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Permalink Reply by Skip Kirkwood on -
You've hit upon an important issue here.
We are working with a failed economic model. We start with "reimbursement" and try to live on it Since the National Medicare Fee Schedule, it really just can't be done.
No other community public service is expected to fund itself through user fees. If it was, all schools would charge tuition, houses would burn down (it would cost too much to use a fire department), cops would only write tickets (and never investigate crime), libaries would turn in to bookstores.
We've got to stop being afraid to address reality. Reality is that EMS should be funded out of local tax dollars, and then communities should get whatever reimbursements are available, but the budget should not depend on reimbursements. What we do is an essential community service, that the community should pay for.
Then, we could invest in activities and training that are good for the community but DON'T lead to transport (or, heaven forbid, actually PREVENT transport), like delivering health services to the medically indigent and homeless, doing public education and prevention, etc., etc. Read about community paramedicine in England, Canada, and Australia - where they don't worry about reimbursement! Many more career opportunities for EMS professionals.
Skip
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Permalink Reply by John W. Magyar on
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Hi Skip,
I see you were a Navy Corpsman as well and have been in EMS for as long as I have. Its good to see others who are still in EMS after such a long career. Many of my old friends have hung it up for retirement.
I agree with your idea of funding EMS through local taxation but the problem is how to make the transition. Many rural communities have grown so used to depending on the local vol. fire,rescue,EMS services for free or through subscription programs that they take it all for granted. With many small municipalities already in the red and the elected officials not understanding or appreciating what the volunteers do, its a hard sell to get tax money. A problem with tax money is this. In Pa., the state allows up to approx. 5 mills for fire tax. Its up to the local municipalities to determine how much of the max. fire tax to assign to the vol. depts. . I just talked to a lady today who said their vol. fire dept. gets NO fire tax at all, while my Borough gets less than 2%. We have an EMS tax in Pa. which allows up to approx. 3 mills. Most companies I know of don't get any EMS tax at all. It all comes down to politics; local, state and federal.
I also agree with your idea of utilizing EMS for "other" medical functions as you mentioned. Public education on safety, health screening etc. could be valuable services we could offer to our communities.
And, not everyone needs to go to the ER in an ambulance just because they called 911 for a ride.
Many treatments could be delivered in the home if the scope of practice would change a little for medics. My son JJ told me this was the next big change coming in the future for EMS.
I wonder how a "Public Health Service" model would work out. I have a friend who works for PHS at a Federal Prison Complex and he seems to think his system works pretty well. The only drawback I see to a PHS model is that medicine would become socialized and under govt. control. Since the govt. so far hasn't proven to me that they can handle other problems very well, I worry that they would really screw up EMS. If the govt. would "partner" with existing EMS organizations, I think that would be a better model and still allow us to direct our own show. Either way, we are going to have to depend on subsidies in one form or another from our governments. I can see the financial benefit of the govt. offering group purchasing, group insurance and other employee benefits as a partner and still allow us in EMS to chart our own course.
Thanks for your comment and hope to hear back from you soon.
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Permalink Reply by John W. Magyar on
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Tonight we completed Phase l of our 3 phase plan by our RR&R Committee. Tonight we put on an EMS Legislative Workshop for our State and Fed. Legislators as well as the Borough and Township officials and county commissioners. We had a surprisingly good turnout with approx. attendance of 50 guests. 80% is great considering that sleet and snow started about the same time as our program. We had 3 experienced local EMS presenters speak on RR&R and then we had a panel discussion with our county Medical Director, EMS Council Director and presenters answering questions from the audience. There were many questions asked, especially by township and borough officials.
We also displayed ambulance equipment with cost of same on a card next to the equipment. We displayed Medicare Billing manuals, Act 45, and a host of other resource material to help the officials understand that EMS is "more than just a ride to the hospital". They now have a real appreciation for what EMTs and Paramedics go through just to complete a call.
I was happy with the questions and comments. While many officials in small municipalities were frustrated with the fact that Pa. law now assigns the legal responsibility for the provision of EMS to them, the point was made that its time for EMS organizations and elected officials to work together in order to preserve and improve EMS. Some officials admitted that they previously had "concerns" about EMS but after the presentations said they had "fears" now that replaced their concerns. Although we did not plan to scare anyone, we did get their undivided attention.
In conclusion, the stage is now set to move on to Phase ll and develop an EMS Task Force with all stakeholders being invited to participate. I'll keep you informed via this discussion group of our progress. If anyone has any questions or comments, please feel free to share them with other members of this group. Be safe out there !! John
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