MT. IRON- All of the presenters and attendees at an emergency medical services forum last week at the Range Association of Municipalities and Schools offices were familiar with various aspects of ambulances services, but after two hours of pooling their collective wisdom, a sobering theme emerged: without systemic change driven by embracing EMS as an “essential service,” the future of emergency medical service in greater Minnesota is in peril.
“We’ve got to fund EMS as an essential service. Why is EMS expected to either break even or make money?” Virginia Fire Chief Allen Lewis said. “We don’t ask our cops to do that. We don’t ask our fire departments to do that. For some reason, EMS is not deemed an essential service. The state and our legislators need to take that up. They need to make the EMS an essential service and they need to fund it. Otherwise, you’re going to call one day and you’re not going to get that ambulance, and I’m not being melodramatic.”
Lewis, who oversees an area Advanced Life Support (ALS) service, was one of six expert panelists assembled by RAMS Executive Director Ida Rukavina to lead the discussion.
“We have to combine resources, we have to combine districts, we have to combine services at some point, and we have to start looking into how we deliver what is needed for that patient,” Lewis said.
Lewis was joined on the panel by area EMS directors Erik Jankila, Hibbing Fire; Therese Elverum, Eveleth Ambulance; Donna Hoffer, Orr Ambulance; Dustin Moravitz, Ely Area Ambulance; and Jessica Davis, Chisholm Ambulance. Each took turns responding to questions posed by Rukavina covering aspects of EMS services from staffing and funding concerns to service provision and needed government and regulatory support.
A diverse audience of over 100 attended in person or via Zoom, including elected and appointed officials from all levels of government.
Almost all of the topics discussed echoed findings from a statewide EMS needs assessment conducted in 2002, but across the intervening two decades the issues have become magnified and more complex while little has changed in basic support.
The most extreme example of a lack of change was offered by Elverum.
“A date that is burned in my mind is October 9, 1984,” she said. “That is when the county decided on the reimbursement rates for ambulance services of $16 a call and 22 cents a mile. It has never been increased. There’s something wrong with that.”
Staffing
When asked about her greatest challenges, Hoffer’s immediate response was all too familiar to her colleagues at the table, that of having adequate staff to provide coverage.
“A lot of days our coverage is limited,” she said. “Night times are better, weekends and Saturdays are a challenge.”
Moravitz agreed, noting that it was often difficult to cover a 24-hour period with two crews.
Most expressed the need to raise compensation, while also noting crew members are in it to be of service rather than the pay.
But issues with staff go well beyond pay, panelists said. Service is taxing on their mental health, not only from the kinds of cases they encounter but from the change in the types of calls they respond to.
“When I started doing this a long, long time ago, we didn’t do as many transfers as we do now,” our transfer volume in the last probably six, eight years, it’s quadrupled,” Lewis said. “Thirty-three percent of our calls are interfacility transfers. That really takes a toll on the staff when they’re out for three hours sometimes, and most of our transfers are actually mental health. That’s been a bit of a challenge keeping up with that.”
Elverum said many of their longer runs are unanticipated at the outset because the emergency room at Essentia Health-Virginia is too small to handle a five-times increase in annual patient load.
“It was built for just 6,000 patients a year and they’re hauling in 6,000 patients a year just in Virginia,” she said. “It is almost 30,000 patients a year now and nothing has been done to that. There’s can be a four to six-hour wait time and so we’re transporting to the next closest hospital. Instead of going to Virginia, we’re overwhelming Hibbing.”
All agreed that the volume of interfacility transfer calls is putting extreme pressure on their staffing, often leaving smaller service areas uncovered and dependent on mutual aid because they don’t have the personnel to fill two crews simultaneously.
Staffing is also an issue with first responder units, as is actual response when called out. Lewis said he was aware of one unit where the response rate from first responders was only about ten percent, while most hover below 50 percent. It was also noted that responses dropped off significantly during the COVID pandemic as many older responders were wary of exposing themselves to the virus.
Finance
Ambulance funding is a piecemeal mix that varies across service areas and is a mix of fee-for-service and differing levels of governmental support. Whatever the mix, it isn’t enough, Jankila said.
“We build up millions and millions of dollars with the services that we collect, and that still doesn’t cover what it costs us to operate,” he said. “There haven’t been the funding levels. It doesn’t matter if you’re in Tower Ambulance Service or Cook Ambulance Service, we don’t get reimbursed nearly the cost of operations on 911 calls. When we look at the funding mechanism, the honest truth is that the funding is in transfers. Transfers can help rejuvenate the revenue stream. So as an administrator, we want to take those transfers to help the bottom line to keep us operating”
The trade-off for more transfers is increased stress on staff from more calls and longer hours. And in the case of 911 calls, if a BLS service has to call for an ALS team to provide more intensive care for a patient, that compensation can evaporate altogether.
“Eighty percent of our calls are Medicare and Medicaid, for which we are reimbursed $547,” Evelum said. “Right now, if I call for an (ALS) intercept I have to pay them $600. I’m $50 in the hole.
Panelists made appeals to legislators and officials to sponsor initiatives and bills to increase financial support for ambulance services. St. Louis County Commissioner Mike Jugovich said that a realignment of the seats on the board of commissioners has opened a window to push for additional support in his county.
“For the first time in the history of St. Louis County you have four rural commissioners,” he said. “We have talked. I have made four different runs at taking care of ambulance runs in unorganized townships and failed every time. We won’t fail this year.”
Jugovich acknowledged that was a small start, but that he and his rural colleagues are willing to look at other options for more support.
Jugovich also said that the federal government needs to step up to reimburse emergency services delivered in the Boundary Waters Canoe Area and Voyageurs National Park.
“We’re supposed to support emergency services in the Boundary Waters and we get nothing back from the feds and we’ve tried,” he said.
Numerous other speakers addressed other issues, but in the end the panelists agreed it all comes back to making a legislative commitment to EMS as an essential service.
“Having a perspective coming from out of state where things are run much differently, I don’t feel like EMS has the priority in Minnesota than it does in a lot of other areas,” Davis said. “When you call 911, you want the ambulance there, you don’t want to have to think about it, you don’t want to have to explain anything. It’s the expectation. Every single one of us deserves to have that expectation and haven’t realized. And I think a lot of that will be assisted by becoming an essential service”
Lewis emphasized that the commitment needs to be made up and down the governmental line.
“We have to have government engaged at all levels, local townships, cities, state and federal to address this issue. No one person is going to address all this,” Lewis said.