SOUDAN- The challenges facing rural EMS were the focus of a roundtable discussion here last Thursday that brought nearly three dozen local stakeholders and interested community members together to talk about possible solutions with state Sen. Grant Hauschild.
The meeting was part of Hauschild’s newly-announced “Northland Strong” initiative, a plan to focus on outreach and policies that create strong families, safe communities, outdoor heritage, innovative economies, and a state that works, according to a press statement.
Ambulance service directors and volunteers, as well as city officials and other involved individuals from Tower, Ely, Babbitt, Cook, Orr, Hoyt Lakes, and St. Louis County were invited to participate.
“There is broad agreement that what is happening now is not working,” said RAMS Executive Director Paul Peltier, who helped moderate the discussion. “That is why we are here.”
“EMS was one of the top two issues I heard when I was campaigning,” Hauschild told the group. “And I know if we are going to get things done, I need to learn as much as I can from the people who deal with these issues every day.”
Hauschild said he is seeing that one of the more effective ways to advocate in the Legislature is to create regional partnerships.
“If we don’t unite, we will miss out,” he said. “We need to be together as one region.”
Hauschild said he will bring the information he is gathering to the governor’s office and hopes to see a task force created to look for solutions to the issues facing rural ambulance services.
He noted that one of the greatest challenges for rural ambulance services is the federal reimbursement rates paid by Medicare and Medicaid, which cover only about a third of the actual costs of serving those patients.
“I am not afraid to advocate at the federal level,” Hauschild said, “and have been working with Sens. Amy Klobuchar and Tina Smith. But I am also looking at statewide solutions.”
While such solutions will not happen quickly, Hauschild said he was committed to working on this issue and said he will be inviting many of those in the room down to the state capitol during the session.
Area ambulance service directors and representatives from Tower, Cook, Ely, Hoyt Lakes, Babbitt, and St. Louis County all had similar things to say, with financial support and staffing issues topping their agendas.
“We had 908 runs last year and lost money,” said Hoyt Lakes Ambulance Director Melanie Olmstead. “Last year we lost $85,000.” Ambulance services in Tower and Ely are also facing large shortfalls. Meanwhile, finding staff was the largest issue facing the Cook Ambulance, said Cook Mayor Harold Johnston.
Duane Johnson, the 911 Emergency Operations Manager for St. Louis County, said his largest worry is when a 911 call comes in and there isn’t an ambulance service available to take the call.
Transfers from the smaller hospitals in Cook, Ely, Virginia, and Hoyt Lakes are taking a larger share of ambulance calls. Often these are for emergency situations, where patients can receive lifesaving care for heart attacks and strokes that aren’t available at smaller hospitals. Recent trends which have consolidated more specialized medical care in Duluth also means that more patients need to be transported to Duluth for care. These calls take highly-trained personnel out of their regular coverage area, often for four hours at a time.
Johnston said he is seeing more and more pages going out three times before getting a response. “Back in 1995 pages got answered right away,” he said. “But now people are working two jobs, and recruitment and retention is a huge issue, not just here but nationwide.” Johnston noted that more fire departments are shutting down for lack of personnel, including Greaney-Rausch-Silverdale a few years ago, and Evergreen set to close at the end of this year.
“St. Louis County is the sixth-busiest 911 call area in the state,” Johnston said, getting 600-1,000 calls a day. While the majority of these calls are in Duluth, the rural call volume has expanded greatly, especially with the wider phone coverage created by cell phones.
The costs of operating rural ambulance services have also been steadily rising, with equipment, ambulances, and medical supplies a major factor, as well as the requirement to have on-call staffing 24/7.
Ely City Clerk-Treasurer Harold Langowski recalled that when the Ely Joint Powers Ambulance Board was formed about 15 years ago, it did work. But now, with the wages that are required to operate an ALS (advanced life support) service, it is no longer financially viable under their current joint powers agreements.
“The joint powers is looking at an operating gap of $60 per capita,” Langowski said, noting that the arrangement began with a $5 per capita payment by the city and surrounding townships, which has since been raised to $10.
“We don’t expect people to work for poverty wages,” he said. “We need a permanent solution, regionally.”
Response times in rural areas are also troublesome, with coverage areas so large that it can take up to a half hour to get an ambulance on scene. This also means that when an ambulance goes out, it can take two hours to do a call to a local hospital, but four hours for a transfer call, meaning on-call staff is out of their home territory for long periods of time.
But even the economics of shorter range calls are astounding.
Olmstead said she needed an ambulance at her house, 18 miles from the Hoyt Lakes station. It cost them $1,122 for that run,” she said. “We charge $1,758, and Medicare pays us $476. We lost $645 on that run.”
“That’s the worst word problem you’ll see in school math,” said Peltier. “It’s an example of why it is working so poorly.”
Depending on the ALS service provided by Virginia is getting tougher. Tower Ambulance Director Dena Suihkonen said while Virginia has five rigs, they have been struggling with staffing.
“They are overwhelming their people,” she said. “They have paramedics out for work-related injuries.”
It was also noted there is little to no financial incentive for larger ambulance services to cooperate with smaller rural services.
Hauschild asked about creative ways services have found to increase efficiency and cut costs.
Tower City Clerk-Treasurer Michael Schultz said staffing costs are a large piece of the puzzle, but if services try to cut on-call pay, they risk losing staff.
“It’s a catch-22,” he said.
Hoyt Lake’s staff talked about the high cost of equipment needed for the ambulance. Olmstead said replacing a relatively new pulse oximeter was going to cost $800 for a unit that also read carbon-dioxide levels. They ended up ordering a less expensive one, that doesn’t measure carbon dioxide.
Hauschild noted that smaller cities do not have the staff available to handle all the paperwork required.
“When we pass legislation,” he said, “we have to understand the capacity of rural governments.”
Hauschild said his goal would be to enact some new funding sources that would be simpler to oversee.
There was some discussion on the existing primary service areas (PSAs). Ambulance services are required to cover these areas, but there is no requirement that these areas contribute financially to the operation of the ambulance service that covers them.
While fire and police protection are considered essential services in Minnesota, with some state funding, ambulance service is considered non-essential.
“The state says we care for you if your house is on fire or if someone steals from your house,” said Olmstead, “but not if you have a heart attack in your house.”
“We see four or five fires a year in our area,” said Suihkonen, “but get over 500 EMS calls a year.
Hauschild talked about options for creating tax districts for ambulance services, which could be either on a per capita or per parcel basis.
Staff from both Ely and Hoyt Lakes said their services are in danger of shutting down in the next year or two, due to funding shortfalls. Tower noted the city is already subsidizing the service, but that this is not sustainable.
“I’m not saying this is going to be easy,” said Hauschild. “But it is important to talk about. We need to put pressure on elected officials. I know this is a real challenge.”
“You aren’t thanked enough,” he added. “You face trauma providing these services. Solving this is a top priority for our area.”
Hauschild said he plans to keep in contact with ambulance and city leaders on this issue.
“We will be working on a bill to fix the Medicare gap,” he said, “and we can look at options for taxing districts. Saving peoples’ lives is very important.”
Peltier said this issue will also be a top lobbying issue for RAMS.
“This is an issue that affects us all,” Peltier said. “One Range, one voice.”