By Zach Jaworski
The Citizen
CAYUGA COUNTY, N.Y. — Providers of emergency medical services in Cayuga County had to step up when American Medical Response pulled out of the area at the end of 2023.
AMR, the largest private ambulance company in the U.S., attributed its decision to leave to rising equipment costs, a less qualified post-COVID-19 workforce, and reimbursement rates it called stagnant.
While local EMS providers have been able to respond to all those calls that would have gone to AMR, they’re still facing the same problems that prompted the company to leave.
“All the ambulances are struggling,” Matt Smokoski, director of Four Town First Aid Squad in Moravia, told The Citizen. “There is a huge problem all over the place.”
Cayuga County has seen its own EMS exits as well. Ambulances operated by the Weedsport, Union Springs, Conquest and, most recently, Fleming No. 2 fire departments have all ceased operations over the last decade and a half. According to a 2024 report from the New York State Comptroller’s Office, between 2019 and 2022 the state’s active number of EMS providers declined by 17.5%.
When it comes to those closings, Cayuga County Director of Emergency Services Riley Shurtleff told The Citizen that equipment costs, low pay and a less interested workforce all have a seat at the table.
“It costs $3,500 a semester for two semesters and what’s basically a college class to become a paramedic,” said Shurtleff, noting the basic emergency medical technician training cost can be high as well.
Those costs are usually covered up-front by the department, provider or trainee until they can get reimbursed by state. But there are also other costs providers have to keep in mind, Shurtleff said.
“A new ambulance costs $280,000, and EMTs and paramedics are getting paid at an hourly rate,” he said. “When you’re trying just to maintain operations, basically, EMS is a losing game.”
‘There’s always going to be a shortfall’
For small volunteer EMS providers like Four Town, the main source of funding outside of community donations is insurance claims.
That’s mostly Medicaid — but it only pays for about 40% of ambulance rides. Earlier this year, the United New York Ambulance Network sent a letter urging providers to tell their local assembly members and senators to push for increased Medicaid reimbursements. According to a news release from the network, Medicaid pays less in New York than in all surrounding states.
“Reimbursement from the insurance companies is not enough to allow an ambulance to survive and work,” Smokoski said. “There’s always going to be a shortfall.”
Smokoski said one solution being floated to mitigate that shortfall is a New York State Senate bill making municipal ambulance services essential. But the bill has been in legislative limbo since 2021.
Jackie Dickinson , executive director of Southern Cayuga Instant Aid, believes that the resulting municipal funds for EMS could help ensure paramedics and technicians are compensated better.
“New York state needs to make EMS an essential service,” Dickinson told The Citizen. “So we can pay providers a living wage.”
Shurtleff agrees, but worries that the legislation would not guarantee additional funding unless it was explicitly written into the law.
“There still has to be financial support,” he said.
“If you tell a town tomorrow to raise an ambulance that’s only ever had volunteers, there needs to be financial support for this to happen. But where is it gonna come from?”
As of 2022, Cayuga County put $0.15 per resident toward ambulance services, according to the state comptroller’s office.
Of the 15 counties with that data available, Cayuga edges out just Orleans . The median amount paid per person by those counties is $1.41, and the average is $11.88.
‘We’re so fragmented’
Kezia Sullivan, director of operations for Auburn City Ambulance, believes the state legislation could be helpful to EMS providers. But for now, she’d like to see better collaboration across Cayuga County.
“We’re so fragmented, it’s our biggest weakness. There are so many agencies, so many small ambulance services, and many different kinds of ambulance services,” Sullivan told The Citizen.
“Neither of those things are necessarily bad, but there is a lot of room to collaborate.”
That fragmentation has led to confusion about which ambulances can respond to an emergency. Sullivan said 911 dispatchers often send more than one, typically the first- and second-closest, because they’re not sure if both are staffed and need to ensure someone responds. But a town can be left vulnerable when its ambulance has to cover an emergency in the town next door.
Additionally, the only provider being compensated for responding is the one that transports the patient, if one is transported at all.
“The real cost of running an ambulance company is readiness,” said Sullivan, noting that EMS providers do not generate revenue when on standby.
One solution brought up by both Sullivan and Smokoski is a dispatch system that would assign priority levels to emergency calls.
They believe this system would help service people better and make sure limited resources are going to the most urgent situations, like cardiac arrests and traumatic injuries.
The system would reserve advance life support ambulances for those situations, leaving the county’s other type of ambulance, basic life support, for the rest.
Providers of emergency medical services in Cayuga County aren’t entirely sure how those services will look beginning in 2024.
‘It isn’t getting easier’
Even as Cayuga County EMS providers face these problems, call volume continues to increase, Shurtleff said. But the cause is hard to pinpoint.
“At no point in time has there been a location that was not being covered by an ambulance,” he said.
“But I do think we have a rise in call volume because of an aging population, as well as a national trend of non-emergency calls because wait times are so long at primary care providers or urgent cares.”
Matt Kidd, a volunteer for Fleming Fire Department No. 1’s ambulance, said the amount of time EMS staff spend with patients at hospitals is increasing because they are also understaffed.
He believes that time commitment, along with costs, may be turning some people off from becoming or remaining involved with EMS.
“The turnaround time for a call has definitely increased. With not only the hospital but the regulations from the Department of Health and you got to do your paperwork and restock the ambulance and clean it,” Kidd said. “As a volunteer, you know, I’m coming from home, I’m leaving my family to come do the call. A lot of us don’t mind doing it, but that’s tough on us as well.”
Even as more problems emerge for EMS providers across Cayuga County — from increasing calls and costs to decreasing reimbursement — Shurtleff believes those providers will continue to push forward.
“This is not a simple answer, this is not a one-size-fits-all,” he said. “I can tell you that 911 calls will not go unanswered, but it isn’t getting easier.”
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