Ambulance service: Rising costs, coping strategies

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Sunday, September 23, 2007

Ambulance service: Rising costs, coping strategies

By John Davis

Poughkeepsie Journal

A sharp hike in the cost of ambulance service and decline in rescue squad volunteers have small towns in Dutchess County exploring sharing emergency medical services.

After years of running deficits, Alamo Ambulance Service told several towns it serves fees would be rising, in some cases by more than 400 percent. The largest provider of ambulance services in the county said rising payroll expenses, increased demand for services and decreases in Medicaid reimbursements have driven up costs.

As a result of the higher fees, several towns are exploring ways to save money and still ensure services for everything from general illnesses and broken bones to heart attacks, fires and traffic accidents. In 2005, 30,807 ambulances were dispatched by the county 911 center. Last year Alamo responded to 25,994 calls dispatched by 911.

"A majority of them are for illness," said Howard Adams, emergency medical services coordinator for the Dutchess County Department of Emergency Response, mentioning heart attacks, cardiac arrest, stroke, seizure and diabetic emergencies.

In June, Beekman's monthly fee increased from $3,500 to $18,115. This covers 24-hour service, seven days a week.

"Alamo came to Beekman in March saying they could no longer provide service at the cost we were paying," Supervisor John Adams said.

The town is exploring sharing costs with the towns of Pawling and Dover and the Union Vale Fire District. The neighboring communities have formed the Southeastern Dutchess Ambulance Consortium that is looking at how a regional ambulance district might be formed and how the towns could divide ambulance coverage.

Pawling saw its Alamo rates nearly triple in one year. Last year, Pawling paid Alamo $130,000 for around-the-clock coverage. It is paying $360,000 this year.

Supervisor Beth Coursen said cooperation between the members of the consortium bodes well for reaching an agreement soon.

"It's my hope we can move it forward," she said.

The members of the consortium are beginning to realize being willing to share ambulances with neighboring municipalities is going to be the way to cut rising costs.

"There seems to be a lot of idle time we're paying for ambulance service," John Adams said.

Depending on what ambulance firm the four communities in the consortium decide on, they must then decide how to divide the cost based on their geographical size and population. They also will need to determine how many ambulances would cover the area and where they would be based.

"We still need to decide how we're going to divvy up the cost," John Adams said.

Based on its geographical size and population, each community will pay a different amount. Ambulance bays would not be stationed in each community, but would be where crews could respond in adequate time to any emergency in the consortium territory.

The Beekman supervisor is hopeful an agreement can be reached this year. Each member of the consortium would then sign an individual contract with the ambulance provider. The contract would be subject to a town board vote, and in Union Vale, approval of the fire commission.

Ray Eaton, a longtime resident of Beekman, is encouraged by the plan to share the cost of ambulance service with neighboring towns.

"I think it's a super idea if it can be worked out somehow," Eaton said.

Support from county 911

These budding partnerships are winning the support of Dutchess County 911. The emergency response center has been studying ways to improve ambulance service across the county at the lowest cost.

"You are kind of forced to consolidate services," Howard Adams, the emergency medical services coordinator for the county, said.

It's the cost, not the service, the Alamo paramedics and emergency medical technicians provide that is the issue for consortium members.

"The crews we have out here with Alamo are No. 1," John Adams, the Beekman supervisor, said.

Other towns in the county also have seen sharp increases in the cost of Alamo ambulance service. That is generating interest in looking at ways to reduce emergency medical costs.

Pleasant Valley saw its Alamo costs increase this month from $1,054 to $9,366 a month.

Alamo provides full ambulance service from 5 a.m. to 5 p.m. Monday through Friday. Volunteers with the Pleasant Valley Rescue Squad provide ambulance service and basic life support coverage during the evening and early morning hours and on weekends.

Alamo also provides Pleasant Valley residents advanced life support "for critical emergencies" throughout the week.

Alarmed at the cost increase, the town board recently formed a committee to study the most affordable way to provide ambulance service for Pleasant Valley residents.

Hikes were overdue

For Alamo and other ambulance services, the price hikes in towns such as Beekman and Pleasant Valley were long overdue and were needed to address rising operating costs, higher salaries for crews, increased demand for services and lower Medicaid reimbursements.

"A lot of ambulance companies were subsidizing service for some time," said David Ping, vice president for strategic planning and business development at Health Quest, the Poughkeepsie-based health-care system with which Alamo is affiliated.

A new management team that arrived at Health Quest last year, identified the shortfalls, Ping said.

"We knew we couldn't keep losing money at the rate we were," he said.

The delay in addressing the shortfall was, in part, Health Quest allowing the towns Alamo serves advance notification of future fee increases, spokeswoman Theresa Mulkins said.

"Yes, they were losing money, but they wanted to give the towns some lead time," she said.

Alamo faces rising operating costs due to increases in paramedic salaries, need for more staffing and higher fuel prices.

The increase in salaries paid to ambulance crews is a major reason operating costs are rising.

A shortage of qualified paramedics and emergency medical technicians has driven those salaries up, Ping said.

Emergency medical technicians can provide basic first aid and CPR and operate a defibrillator. Paramedics are qualified to dispense medication and clear a patient's trachea or breathing passage, Howard Adams said.

'Tough job'

The work for the ambulance crews can be demanding.

"It's a tough job. When's the last time you carried a 350-pound patient down the stairs?" said Scott Woebse, vice president and chief operating officer for Mobile Life Support Services, a Newburgh-based ambulance firm.

Paramedics, who have typically logged 2,000 hours of classroom time to achieve certification, have found with a little more study and training they could become nurses or physician's assistants and make more money, Ping said.

A reduction in Medicaid reimbursement for ambulance service in 2002 also contributed to the Alamo budget shortfall.

"For five years, we kind of ate the costs on that," said Marc Reina, general manager of Alamo Ambulance Service.

Another major factor in the increased operating costs for commercial ambulance companies is the dwindling numbers of volunteers in local fire department rescue squads.

A decline in volunteer emergency medical technicians over the past several years had led many local fire departments to eliminate their rescue squads. Pawling fire department did so about five years ago and, in the past year, Staatsburg and Hyde Park fire departments quit operating ambulance vehicles.

"The (basic life support) has been historically served by the volunteers," Howard Adams said. "The people who have done so for the past 30 years have done it well."

Because of this shortage of volunteers, ambulance companies are responding to the basic life support emergencies that usually only require first aid for injuries or minor illnesses.

"When we began this company 15 years ago, we started just assisting them," Northern Dutchess Paramedics President Ed-ward Murray said of the local rescue squads.

With the decline in volunteers, ambulance companies have had to increase their own staffing, which, with the shortage in qualified personnel, has substantially driven up operating costs.

"In order to take on the primary role, it means increasing staffing," Murray said. "Now we're providing (basic life support) and (advanced life support)."

Basic life support is first aid for minor injuries and illnesses. Advanced life support is care and treatment for life-threatening injuries, heart attacks, strokes and other illnesses.

Contracts differ

Commercial ambulance firms have different contracts with each community.

For example, under Northern Dutchess Paramedic's contract with the Town of Dover, the company provides around-the-clock service, seven days a week. What the company charges the town, Murray said, is based on the cost of maintaining an ambulance in Dover, including salaries for its crew. From that operating cost, the revenue reimbursed to Northern Dutchess from its customers' insurance companies, including Medicare and Medicaid, is subtracted. The difference is the annual subsidy the company charges the town.

The increased operating costs for commercial ambulance firms is being passed on to the towns, not the customers, Murray said.

"The patient is relatively unscathed," he said. "Most patients' insurance covers those bills."

When Hyde Park resident Joseph Strong fell in his house and fractured his left hip a little more than a year ago, it was Alamo that transported him to Northern Dutchess Hospital in Rhinebeck.

He can't remember how much the ambulance bill was, but he was responsible for paying half of it, which he was able to do in two installments.

"Medicaid took care of some of it," Strong said.

He has medical insurance, but it requires he spend $4,000 of his own money each year, the deductible, before reimbursement is provided.

"Alamo did a good job," Strong said.

Like the communities in the Southeastern Dutchess Consortium, there is talk in Hyde Park about forming a townwide ambulance district instead of having several districts. Having all the residents share the cost could make ambulance service more affordable.

Hyde Park Supervisor Pompey Delafield favors the idea, as does the Roosevelt fire chief.

"We want to make sure people in Hyde Park have a reliable quality service," Chief Bill Steenbergh said.

Consolidation is proposed

Forming a townwide district makes sense, Murray said. Because of the way the town is divided into several fire districts, there are more commercial ambulances serving the town than necessary. By going to a townwide system, fewer ambulances would be responsible for the same geographic area.

"I would consider that a wise financial choice," said Murray, who is also president of the Dutchess County Emergency Management Council.

Concerns about increased response time to ambulances will not become an issue, Murray said, if there remains a healthy pool of first responders in each community.

These individuals, be they police or volunteer firefighters, can be the first to arrive on the scene where someone is ill or injured, providing first aid and comfort until the advanced life support crew arrives in a commercial ambulance.

Howard Adams is consulting Hyde Park town and fire officials, who recently met to discuss the concept of a townwide ambulance district.

The regional ambulance system, he said, is the model of the future.

A number of communities in the northeast part of the county, the villages of Millerton, Millbrook and Tivoli and the towns of Amenia and Stanford are also interested in the regional ambulance concept.

"You have municipalities taking steps to fund this," Howard Adams said.

Reach John Davis at jpdavis@poughkeepsiejournal.com or 845-437-4807

[ny10570 745]

Wishful thinking, but hopefully this is the opening for municipal EMS.

[MerlinMedic 5]

Looks like a balanced, well researched article. I especially like the quote from MLSS about the 350 pound patient .

Also shows that the governments are thinking. That is good.

[orangEMT246 6]

This sounds like the future of EMS if going municipal is just to expensive to do. Talk is good, but lets see how many of these new "ambulance districts" actually pan out. Hopefully the politics won't get in the way. But I see the placement of the ambulance bay being a problem ie... Pawling wants it in their town while Unionvile wants it in their town.

[trauma74 111]

These problems plague EMS all over the place. I was talking with my cousins who ride for a VAC in NJ and they were telling me about some of the same problems.

What all municipalities need to realize is that providing 24/7 EMS is not going to get cheaper. It is going to become more expensive. For years the true costs of EMS have been ignored. There is no quick fix or solutions in sight. Many elected officials fail to realize that a VAC is a business and it must run that way in order to survive. The days of the "mom & pop" VACs are over. The responsibilites of the officers of a VAC are more than ever before. Back in the day, there was not a lot of money to deal with. Now, hundreds of thousands of dollars are being collected thru third party billing. We have all heard about the agencies who have been ripped off by their treasurers. Many VACs now pay accountants and bookkeepers to manage their money.

Towns and Villages like to save money, but cutting EMS is not the way to go about it. Looking for a bargain with EMS is something that should never consider. You cannot put a price on the lives of the residents that you serve.

Edited September 24, 2007 by trauma74

[Guest EFFP411]

This is becoming more and more rediculous every day. When it comes to fire and police, they have no problem with getting funds for them, but for EMS, they constantly seem to try to "squeeze blood from a rock" (no pun intended), and save every buck they can. I don't know about you, but i could care much less about property and money when peoples lives are at hand, and they need to figure out what is more important fast

[helicopper 1,050]

This is becoming more and more rediculous every day. When it comes to fire and police, they have no problem with getting funds for them, but for EMS, they constantly seem to try to "squeeze blood from a rock" (no pun intended), and save every buck they can. I don't know about you, but i could care much less about property and money when peoples lives are at hand, and they need to figure out what is more important fast

I'll grant you that municipalities try to get blood from a stone when it comes to EMS but don't for a second think that the FD's and PD's are getting carte blanche. Municipal budgets are getting tighter and tighter and police/fire are NOT exempt from the microscope. Just look at the Putnam County SO for example - they've been without a contract for FOUR years!

The biggest problem is that for years EMS did whatever it had to just to get by. EMS has always been the "no-frills" emergency service and in most places, it is covered by a VAC which has very little contact with the municipal body. Every PD and most FDs have to deal with the municipality for funding. Fire Districts have a little bit more latitude in that they can levy their own taxes so they don't have to deal with the Town/Village/City on a routine basis.

And you can't simply say "I could care less about property and money" when you've got to pay your mortgage and taxes every month. Sure life safety is paramount, but if nobody can afford to live there - as is becoming the case across the region - what do you do then? Look at the decline in volunteerism. I'm sure there are many people who would like to volunteer but simply don't have time because they're working OT or two jobs just to make ends meet.