By Tawnya Panizzi
The Tribune-Review
GREENSBURG, Pa. — Emergency medical services across Western Pennsylvania have found themselves on life support, despite being in the business of saving lives.
Minimal state and municipal funding, combined with sluggish private donations, has leaders scraping by and some services on the brink of folding.
“It costs us $150 an hour to operate 24/7 whether our ambulance moves or not,” said Ed Grant, Penn Township ambulance chief.
With wages comparable to those in the fast-food industry, medical staff increasingly are looking elsewhere for work.
“Every ambulance service in the Alle-Kiski Valley is way past crisis mode,” said Jim Erb, EMS director at Citizens Hose in Harrison. “We can’t pay our guys fair wages.”
An EMT earns about $15 to $17 an hour, or about $36,800 a year, according to salary.com. Five Guys restaurants and Sheetz pay entry-level workers the same.
Ambulance service officials say the biggest culprit crushing their business model is bottom-barrel insurance reimbursements. Providers get paid 30% to 60% of what they spend to care for patients from insurance companies.
“Life-support services exceed $1,000,” said Grant, whose crew responds to 3,000 calls a year covering three boroughs and 11 miles of the Pennsylvania Turnpike. “We might get $300 back (per call).”
A new ambulance can cost $250,000. A heavy rescue truck to carry multiple personnel can top $1 million. Monthly fuel bills are near $15,000. That doesn’t include salaries, utilities, training and technology costs.
“Everything is trending upward except reimbursements,” said Shane Spielvogle, executive director at North Huntingdon EMS/Rescue.
Earlier this year, the state Senate approved legislation that would provide a $20.7 million medical assistance increase, but the House of Representatives has yet to give it the green light.
Heather Sharar, executive director of the Ambulance Association of Pennsylvania, said delays in funding will hurt the public.
“EMS needs sustainable funding,” Sharar said. “Medicare and Medicaid do not cover the cost to provide services. Honestly, I don’t know what else we can do to make the Legislature hear us.”
State Sen. Lindsey Williams, D-West View, said she believes the state needs to make significant investments for sustainable EMS services.
“We need to increase the Medicaid/Medicare reimbursement rates for ambulance services so providers can cover the costs of the care they provide,” said Williams, whose 38th District includes part of the Alle-Kiski Valley, a section of Pittsburgh and suburban communities in the North Hills.
“We need to provide more consistent funding streams through the budget, not our current system of relying on inconsistent grant funding and overcomplicated reporting systems,” she added. “This will allow our EMS providers to focus on patient care, not fundraising.”
Several rescue agencies across the state have closed in recent months, including Jeannette EMS, which had operated for 63 years.
“If the Legislature continues to ignore our cries for help, more services will close their doors,” Sharar said.
Dwindling workforce
According to the Pennsylvania Fire and Emergency Services Institute, there were 1,645 EMS agencies statewide in 2013. By 2017, the number dipped to 1,278 — a 22% decrease.
In a 2018 report, the institute estimated the number of paid EMS in the state at 17,000, down from a high of about 30,000 — a 43% decrease.
“It’s not uncommon for us to work 16-hour shifts,” Eureka Fire-Rescue Chief Rich Heuser said. “We can’t provide in the 2020s what was given in the 1980s.
“When we go out and give you a bill, Medicare dictates what they’ll give us. Insurance refusal falls back to the patient, and they think their taxes pay the bill.”
Eureka Assistant Chief Brad James said the lack of manpower hits hard.
According to the Hospital and Healthsystem Association of Pennsylvania, more than 2,600 EMTs allowed their certifications to expire in 2021.
Mutual aid agreements send Eureka crews from Allegheny County into Butler and Westmoreland counties once or twice a day, covering a wider area because of a lack of crews across the region.
“We used to be there once or twice a month,” James said. “That’s vice versa, too. Their guys are over here.”
Erb said it is a similar situation at Citizens.
“If we’re getting called out to Cabot or Butler, we’re out for two hours,” he said. “We rely a lot on mutual aid.”
Finances unsustainable
Spielvogle called the current situation unsustainable. His North Huntingdon crew of 44 answers about 5,000 calls a year. They are a mix of paid staff, part-timers and volunteers.
“911 services are lifesaving and critical. You don’t have time to check insurance and reimbursement,” he said. “Reimbursements don’t cover the cost of care. That’s the bottom line.”
EMS should not be excluded as a municipal service that has to “figure it out” on their own, said Penn Township’s Grant.
“EMS is a must,” he said. “Everybody is under the impression that we make our money back.
“It’s not like utilities where you pay or they get shut off. We bill, and they tell us what they’re giving. There is no in-network consideration when you’re having an emergency.”
North Huntingdon EMS/Rescue is fortunate to receive consistent support from its township, Spielvogle said, but, in the face of climbing costs, the municipal support that used to amount to 12.5% of the $2.5 million budget now covers about 9%.
Similarly, Foxwall EMS receives support from Fox Chapel and Aspinwall that accounts for about 10% of the annual budget. A subscription drive to residents brings in another 11%.
“With a combination paid/volunteer service, we operate with a razor-thin margin,” Chief Tony Cuda said. “We are very lucky with the support we receive, but about one-third of our calls are not billable for various reasons, and the cost and preparedness remains the same.”
Among Eureka’s 3,000 calls each year, many are to assist with lifting patients for transportation and welfare checks, which traditionally were considered a service to the community but now cut into paid responses.
“If we don’t transport them, we don’t get paid,” Heuser said. “While we’re standing up Granny Smith and dusting her off and petting the dog, we can’t abandon her and go on a different call.”
James said it’s becoming difficult to perform those good-intention calls because of a lack of personnel and because it costs money to put the truck on the road.
“Insurances don’t like to pay unless there’s a (patient transport),” he said.
The past is gone
There was a time not that long ago when emergency medical services were a well-oiled, profitable machine.
“Ambulance services were successful when we had a lot of volunteers,” Erb said. “We were permitted to bill for services that were provided, and the cost was nothing for manpower.
“We’ve since gone to a 95% paid workforce with annual increases from Medicare of single-digit percentages. It’s not sustainable.”
Erb runs a crew of about 18 paid employees.
He said this year, for the first time in many years, there is a positive ripple felt after the Centers for Medicare and Medicaid Services set the 2023 ambulance inflation rate at 8.7%. That’s the largest percentage increase in the history of the Medicare Ambulance Fee Schedule.
“We can pay the bills,” Erb said. “But for us to pay employees what they should make and also bring people into the field, there is more that needs to be done.”
In Penn Township, Grant has served as chief for more than 20 years. When he joined, services were successful if they had volunteers who were willing to be trained and show up. State-certified training of 80 hours was required to become at EMT. That number has grown to 100 hours.
When Grant became a paramedic in 1993, training was two nights a week and a couple of Saturdays for six months.
“Now it’s equivalent to an associate’s degree,” he said.
It takes a year of study, followed by an internship, to become certified.
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“You put $10,000 into an education and then find that wages aren’t real great. They have increased, but it’s come at a great cost on the other side of what we do,” Grant said.
A paramedic earns about $26 an hour, or about $48,200. Becoming a paramedic requires more training than EMTs.
“When I’m thinking about spending that money to become an EMT, for a little more time I can become an RN and make $33 an hour,” Grant said. “People are looking to be fulfilled, and they want to impact patients. There’s a greater opportunity to expand in the medical field at a hospital.”
What’s the fix?
Leaders said there is no simple solution.
“No. 1 is that insurance has to increase reimbursements to what is set as a fee schedule,” Spielvogle said. “And there has to be municipal involvement and public awareness. The general public would be surprised what small amount is provided because of the misconception of how billing works.”
There has been talk of going to tax-based municipal funding: a mandatory dollar amount to the provider based on the number of homes and businesses in the service area.
For EMS to be funded properly, the financial burden has to shift onto the community, county and state, Erb said.
North Huntingdon conducts a direct-mail fundraiser to about 20,000 homes and businesses, and about 14% donate. It amounts to about $125,000.
“I understand times are tight for everyone and there’s not as much money to be used in other ways, but our margins are lean,” Spielvogle said. “It’s difficult to be able to plan.”
Eureka sends out 10,275 mailers each fall to residents in Tarentum, Brackenridge, Fawn, East Deer and Frazer.
“We have never seen a return better than 38%,” James said.
Grant said his department gets about 30% of residents donating to its fund drive, which helps toward his $1 million operating budget.
The state gives about $10,000, and competitive grants are available through the federal government. Grant’s crew has been fortunate to get $100,000 in Firefighters Assistance Grants over the past 20 years.
To beef up his staff, Grant employs tuition reimbursement through an apprentice program at Central Westmoreland Technical School so teens can start to learn the ropes.
He has hired two full-time EMTs from the program.
“If an EMT wants to go on to be paramedic, they have to go down to part time. They’re critical to our process, and to lose them for more schooling, there should be a better way to allow them to gain credentialing,” Grant said.
At Citizens, Erb has gained three employees from a fully funded EMT class by the Allegheny-Kiski Health Foundation in Harrison. The nonprofit has twice paid for about 20 students to earn their certification.
It is a great way to draw people into the field, Erb said.
Heuser said he applauds the increased training and enhancements, but he has become numb to fixes and solutions.
“It’s a broken record,” he said. “Until they get the reimbursements and the funding resolved, providers will continue to go away.”
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