Rocks and Hard Places - An EMS Paradox

This past Tuesday Rick Wagner posted a story from Face the State to his blog, detailing the nature of EMS operations at the Thornton Fire Department in the northern Denver suburbs. The story carried the headline "City-Run Ambulance Services Double Dip Patients Pockets, Public Till", and detailed the model used by Thornton and other metro Denver cities of providing EMS services through their respective Fire departments.

These departments subsidize their EMS operations by billing for their services. If the billing receipts from health insurance and patients don't pay for the cost of the services, tax revenue covers the rest. This model is essentially the same as that utilized here in Grand Junction.

Mr. Wagner has been a longtime critic of the demise of private ambulance companies in Mesa County, after the County sought to license ambulance services and establish service areas to assure that the entire county had EMS coverage. After the GJFD won the contract to provide emergency service in the City and GJ Rural districts, the bulk of the county's call volume essentially went to them. This has resulted in the departure of the private providers, and the entirety of the county's first-due EMS service now being provided by fire departments.

The central point of the Face the State post, and an associated radio minute, is to put forth what is becoming an old debate; that with the workload associated with firefighting declining, the fire service must re-invent itself somewhat. They also had to put in an anti-union shot as well. Many departments, like Grand Junction's, provide EMS services, as well as specialized services such as Hazardous Materials response, arson investigation, and hazardous device technicians (if you see one running, try to keep up). The EMS component makes up the lion's share of the call volume of most fire departments that provide this service in urban and suburban population centers.

It's very interesting that this past Monday, a Denver Post story seemed to spell out an entirely different perspective on the provision of EMS. The story profiled the struggles of the Morgan County Ambulance Service, a non-profit rural agency struggling with increasing costs and declining reimbursement. The story also mentioned the same difficulties being experienced by a private ambulance company providing service to neighboring Logan County, as well as the challenges of first response EMS in the mountains with Summit County's ambulance service, described on their website as "an enterprise fund department of the Summit County Government".

The consensus from the Post story appeared to me to be that the nature of rural EMS may not be sustainable in the present scheme of things; many are experiencing aging populations and increasing call volume at a time when reimbursement rates and volunteer commitments are declining. Others have lost call volume, but must maintain a high level of service delivery for a population that includes a robust tourist economy.

In many rural areas, these smaller agencies along with hospitals and clinics have taken to call in air medical services to assist with patient care and transport, at times only because a lengthy ground transport to a specialty hospital will leave the remote area uncovered for additional calls. This compounds the problem of under- or uncompensated care at a nearly exponential rate.

Yet all areas share a mandate and a public expectation for these services, whether you are a long-time elderly resident having difficulty breathing, or a traveler passing through on the Interstate who's been injured in an accident. The Post story quotes both a State EMS official and Morgan County's ambulance director asking the same question; what kind of services do citizens want to see provided?

When faced with this question in Mesa County, the two stories referenced above would appear to illustrate a paradox of sorts in terms of how to provide effective service to all citizens and visitors in our area. Based on the above reporting, it appears that private companies are able to thrive only where there is sufficient volume with a reliable revenue stream, such as inter-hospital transports and/or patients who have money or good insurance.

The further away you get from the urban core, the dynamic and the demographic changes to where reimbursement may be sporadic and undependable. In order to provide these services in an efficient manner as dictated by citizen expectation or government regulation, equipment and personnel must be positioned in these outlying areas. This may be difficult to sustain or justify for the EMS provider that is also saddled with a profit motive.

What to do? I guess it depends upon your point of view. If you believe, as I do, that Emergency Medical Services are an essential component of any community's public safety system, then there has to be some reliable, effective means of providing EMS across all population densities, political subdivisions, and socio-economic boundaries.

I've said before that a truly responsive EMS system draws its operating paradigm equally from the symbiotic disciplines of public safety and health care. In many communities it remains the bastard stepchild of both. Here in Mesa County, EMS is provided by the public sector, which is where it belongs.

Recent changes in local EMS support and oversight may provide for both challenges and opportunities in the future. These changes include the elimination of the St. Mary's Hospital EMS office, the growth of Mesa State's EMS training program, and the relocation of Mesa County's EMS Coordinator and Emergency Manager from county administration to the Sheriff's office.

We in our local area should be thankful for the expertise and sacrifices made by both compensated and volunteer EMS professionals to assure that services are available from Gateway to DeBeque, and all points around and between.

Have a good weekend.