Was watching old episodes of Last Week Tonight, and in season eight (2021) there is a discussion of EMS services, EMTs and ambulances in the United States.
Being a paramedic is a difficult job in many ways - physically, mentally, difficult people, applying knowledge and skills in stressful situations, exposure to Covid and other things, personal danger, significant stress and traumatic stresses, yada yada. There are plenty of issues with Canadian services, which vary a lot and tend to be funded by municipalities with different needs and budgets.
But the exposé on American services claimed:
In 39 States, EMS is not considered an essential service, so is poorly funded
25% of EMS services are for profit
Average EMT salary is $36,000 without health benefits; many had no Covid hazard pay and so EMTs sometimes protested against nonrenumerative recognition efforts after Covid
Some 20,000 EMS services exist in the US
Many only get paid if they transport a patient to hospital, so will try to regardless of need (you call, we haul)
This system exists because the original acts mandated funding be local, unlike police or fire
Since ambulances are not essential in most states, communities often wish to spend money in other things
This is why bills might cost $3,000 and many patients prefer to Uber to local hospitals, whose drivers have no equipment, training or know which hospitals offer what services
I assume EMTs require significant education and have commensurate costs
In some places (Houston was mentioned) all ambulance services are out of insurance networks
Many ambulances are owned by KKR or other equity groups seeking to minimize cost and buy up other struggling EMS services
A bill requiring costs to be disclosed up front only applied to air ambulances and excluded ground ambulances, despite providing the majority of services.
Even as a Canadian emergency physician, I found a lot of this quite shocking. Why don’t American federal and state governments do more to stabilize what is clearly an essential service? How could this be improved or changed? Are all of these claims true? Are there areas where people believe their system operates well and efficiently? How can rural systems retain personnel? It seems like a dog’s breakfast…
In the rural town I live in [which has almost 250 people!], EMS is provided by the local volunteer fire department (two or three volunteers have the lowest very basic EMS qualification). For ambulance service two neighboring rural towns (of 1500 people and 1100 people respectively) provide ambulance service (via their volunteer fire departments). I would guess that if I called the ambulance I would get to the nearest hospital (which is about 35 minutes away) in about an hour.
I was going to write an extensive reply, but really it’s already been summed up:
I’ll just note that back in March I discovered that NO ambulance service in my area is in-network for any health insurance company. I was, however, able to negotiate a 30% reduction in price. Still took a bite out of my savings. (And no, in that case, Uber was not a viable alternative. Neither was driving myself.)
It’s still probably worse than you think. It has to be experienced to be disbelieved.
In our town (in Massachusetts), EMS services are partially funded by the town, and partially by charges levied against the patient (which often gets picked up by Medicare because of the age of the patients). Add to that the fact that multiple interstate highways pass through our town, where we might be able to charge back to the state, and it’s all a messy patchwork.
But…we’re a financially healthy town. More rural towns can indeed be pretty fucked up.
ETA the funding mechanism in my town can lead to some messed up incentives. We recently added defibrillators to our ambulances, but only after being assured that not only would they pay for themselves, but at standard Medicare charges might run a profit.
I had been having severe chest pain episodes for weeks when I finally went to the hospital. I had diagnostic tests that showed coronary artery issues and the plan was to stabilize me then try to put a stent in. That procedure would be done at a hospital 4 miles from the one I was in.
I tried arguing that I could drive the distance (I was being practical). They finally convinced me that doing that would entail removing my IV, plus I’d been given morphine. There was an ambulance waiting for me.
Before agreeing though, I called the number on my insurance card and discovered that the ambulance that was there wouldn’t be covered, but an ambulance called from my home area (an hour away) would be fully covered. So I called and requested an ambulance and an hour or so later it arrived, drove me a few minutes away, then left. Full coverage that would have been expensive otherwise.
After my stent was placed and I was discharged, the nurse brought me my morning meds. I turned them down, preferring to pick up my prescriptions on the way home (my gf drove). The pills they wanted me to take would have not been covered, and had a huge markup.
This part, I am pretty sure is not true . But only because police and fire department funding is pretty local , too. There are places in the US with only volunteer fire departments which will not put out a fire at a non-subscriber’s house unless lives or a subscribers property is in danger and places that depend on county/state police rather than municipal police departments. I live in a city where EMS is part of the fire department and while they do bill people , that’s mostly to get paid by insurance. I’ve never heard of them going after people without insurance. ( The problem here is the opposite of people preferring Uber - they call an ambulance when it isn’t needed either because it ends up being cheaper than Uber, or because they think they will be seen faster or both )
But the fundamental problem is that people don’t want to pay for things they think they don’t need - and plenty of people think they don’t need an ambulance ( or a fire department ) until they do.
Well, what percentage of people are under the misimpression that ambulances are generally an essential service (when they are not in the majority of states)? The show suggested even many politicians are also under the misimpression ambulances are considered essential, which they clearly should be.
Really depends on what is meant by “essential services”. I’m not kidding - I’ll try to find the episode and watch in later, but in my experience “essential services” in the US does not refer to services that must be provided/funded by states or localities. It might refer to occupations that are not permitted to strike or services that are permitted to operate during a disaster ( for example, roads are closed due to a blizzard, but emergency workers can travel to work) or government jobs where people still work in a disaster ( Correction officers work during a hurricane but not the clerks in the jail) . I’m not sure anything in the US is an “essential service” in the way you seem to mean , where a state or locality is required to provide a service. You can search the board for a couple of threads on a place with a volunteer fire department where the people did not want to be taxed to receive service from adjoining cities. Probably incomprehensible anywhere other than the US.
The county I live in (King County, Washington) has a very well funded Medic One program. It is subsidized by the voters through an initiative that is voted on every 5 years. The last time there was a vote on the program in 2021, it was approved by 83% of the voters. If it wasn’t for Medic One, my BIL probably would not have survived 2 of his 3 heart attacks and a stroke. Right now the program is having staffing issues, many of the well trained and paid medics are tired of dealing with the gun violence and the homeless in the county and are moving to areas that don’t have these issues. Those are also some of the reasons I plan on moving out of this county in the next 2 years, I’m ready for a slower pace of life.
An ambulance can cost $150,000 between the rig & all of the equipment in it.
An EMT needs 120 hours of training (here), a paramedic needs about 6 months.
For places with paid staff, the rule of thumb is 4 bodies for every position in a 24x7 world - day shift on, night shift on + day shift off & night shift off. Don’t forget to factor in PTO & con-ed (continuing education, not the electric company) so big city depts it’s probably 4.x bodies per shift, while it’s overtime pay at your smaller departments. Don’t forget benefits are 25-33%, or more, of salary so that one $36,000 employee who shows up at your door is really costing in the neighborhood of $200,000; & you have two people on an ambulance
Don’t forget administration making sure everyone is up to date on their various & overall trainings, supplies are ordered, & that meds are being rotated & removed if expired, even by one day.
Again, depending upon where you are you may be able to get something for treat-no-transport but income comes from one of three sources - govt, donations, & fee-for-service
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I can get into more of the operational side, if asked.
I’ve called 911 a number of times over the past years, and if memory serves the responders have always been from Orange County (NC) Emergency services, occasionally with an appearance by the Chapel Hill Fire Department. After checking on my immediate status I was taken to UNC Hospital Emergency Room, which was fine with me as that’s where my doctors are located. I have Medicare and BCBS supplemental health insurance, and I’ve never gotten billed for either the EMT treatment or transportation.
Fair enough, the program implied “essential service” affected funding, possibly because police tend to be better funded and fire services often are (although I am sure there are many exceptions and admit the program could be wrong about this). In Canada the term, likewise, traditionally applied to ability to strike and later to pandemic functionality. I have no idea if being essential affects funding - clearly it need not.
America is irredeemably corrupt. Calling an ambulance for someone here can bankrupt them. As a Canadian, no matter how bad you think it is, it is much, much worse.
Apparently essential services are better funded than many businesses. As a Canadian, doubtless naïve, I still get kind of surprised when I go to places that have drive-thru liquor stores.
I was a volunteer EMT for several years. For America’s uninsured, the ER is often their first time addressing a problem and because they don’t have health insurance, they don’t go to a doctor until it is a crisis that they can’t ignore. ERs aren’t really for treating chronic conditions, they’re for stabilizing patients and then expecting them to get to their doctor for follow up care.
I’ve delivered babies for people who had never been to a doctor prior to being in labor and calling 911. I’ve seen people having heart attacks in a panic over what this all will cost their families.