By Sean Caffrey
Complaints about low pay at the EMT and paramedic levels are a frequent topic of conversation among EMS professionals. News articles regarding efforts to raise the minimum wage in many states and localities often note that EMTs are among the workers who are paid at, or only slightly above, the minimum wage. A recent report from the Glassdoor.com economic research blog showed EMTs holding steady at an average annual salary of $35,984 despite increases in salary of most other health care professions.
As leaders of EMS organizations, especially those that may be part of larger governmental or health care organizations, it is often a challenge to convince our own human resource departments and executive leadership to increase the pay of EMS practitioners. The reasons for low pay are multifaceted and complex. However, understanding some of the underlying reasons why practitioners are not well paid is a first step in understanding what can be done to improve wages.
Unfortunately, some of the reasons why EMS professionals are underpaid can also be unsettling and controversial. We need to explore and discuss these reasons if we hope to move forward as a profession.
Supply and demand is a law of economics
The study of economics is mostly about theory, so it is rare to find something called a law. Supply and demand however, has proven itself to be consistent and reliable over time to earn that designation.
When labor is in high demand and/or not readily available, prevailing wages will be higher.
When labor is plentiful and/or not in high demand, wages will be low.
So how does the law of supply and demand play out in EMS? Results vary from market to market, however, it is likely you may see these trends:
- EMTs are plentiful in most urban areas and often paid near the minimum wage.
- Opportunities for EMT work are often plentiful both inside and outside of the EMS environment.
- Paramedics and nurses, by contrast are usually in higher demand, especially as services upgrade to the ALS level creating significant demand with a more limited supply of workers.
As a result, EMTs don’t make much, but paramedics tend to earn more. Supply and demand, however, is only one piece of the wage puzzle.
2. EMT training is relatively easy to complete
In most places, an EMT course takes about 120 to 150 hours to complete. Candidates need to be 18 years old, have completed high school, successfully completed a course with a textbook written at the 5th grade level and be able to pass a standardized exam.
Looking comparatively at other skilled trades and certainly most allied health professions, this is a relative short course of study. This amount of training and licensing requirements puts EMTs on par with security guards, medical assistants and day care workers. It is probably not comfortable to hear, but it is how the labor market defines and understands us — in comparison to other trades.
3. Paramedic requirements aren’t much more difficult
There is a bit of a national movement to rename all levels of EMS professionals as “paramedics,” using the argument that the profession has no unifying title such as nurse, doctor, police officer or firefighter. In addition, our colleagues around the world have been successful in raising awareness, recognition and pay for paramedics in part through a more standardized nomenclature.
A vocal counter argument is that paramedics have worked hard to differentiate themselves and the title paramedic should not be cheapened by broadening its use. Unfortunately however, the actual difference in professional levels is quite small, which HR professionals have actually been telling us for years.
Much like EMTs, paramedics also only need a high school education, are not required to earn a college degree and participate in relatively little practical education through internship. By comparison, in many states hair stylists must have 2,000 or more hours of training, pilots must document hundreds of hours of supervised training, respiratory therapists must complete a two-year degree and physical therapists are transitioning from masters to doctoral level training as their baseline standard to provide care. Physicians go through at least 12 years of post-secondary education while nursing professional requirements have evolved to a standard that usually requires a four-year degree.
It is increasingly rare to find an allied health profession that requires less than an associate’s degree. What is particularly perplexing is that paramedic program accreditation now requires that paramedic programs meet the standards of college level coursework and most students probably complete their programs only a few credits short of a two-year degree anyway, yet we resist and pay the price in diminished professional status and lower wages.
4. Doing the work for free
EMT training requirements are significantly influenced by what volunteer EMS providers will tolerate. This is not necessarily a bad thing, as this pressure to keep requirements at a minimum acceptable level allows thousands of small communities across the United States to have access to trained ambulance personnel.
The downside, however, is that a significant portion of our labor pool works for no wages and minimal benefits. It is reasonable to assume that this leads many communities to undervalue EMS.
Taxpayers don’t expect a teacher or police officer to work for free, but many communities rely on free labor to provide EMS. If your wondering how this plays out, take a look at a local town or village budget and see how much the local school district requires compared to EMS. If you believe budgets are a reflection of a community’s values and priorities, you’ll get a sense of where EMS fits in the hierarchy.
5. Shifting costs squeezes wages
Some communities have been sold on the premise that EMS can pay for itself by only billing users who request service. While there is certainly a way to take advantage of economies of scale and efficiency in populated areas, the argument that you can entirely support an EMS system only by collecting fees from users has become increasingly suspect.
The premise relies on shifting readiness costs away for the community at large and in turn burdening system users with increasingly large bills. Billing for EMS makes the service free to community members until they actually need the service. But as health care has become more expensive overall, both public and private payers have reduced what they are willing to pay for these services.
This squeeze on revenues leads to an inevitable need to reduce personnel expenses, the largest component of EMS budgets. In addition to the pressure to keep wages low, reductions in fee-for-service revenue limits funds for benefits, training and other non-essential services that can improve the attractiveness of an EMS service to potential employees.
It seems unlikely that petitioning Medicaid, Medicare and private insurers for a few more dollars will address the fact that many communities simply don’t pay for EMS readiness like they do for other community services. EMS services that are partially or fully paid for by the public at large, such as those in fire departments and governmental third services, often pay substantially better and frequently serve as a destination for practitioners who work in other system types.
6. Labor unions impact wages and benefits
This topic elicits passionate discussion from those who may be pro- or anti-union, however, almost any broad comparison of EMS systems reveals that unionized paramedicine practitioners, such as those frequently found in fire service, governmental, and sometimes hospital and private systems, generally have better wages and benefits than their non-union counterparts.
This doesn’t mean non-unionized services can’t be employers of choice, it does mean EMS leaders have to be aware of how they compare to unionized operations and they should be aware of what they can do to be sure wages, benefits and working conditions are equivalent or better. Currently, EMS field providers only have a few strong unions outside of the fire service, especially when compared to paramedicine colleagues in Canada who are almost universally unionized and relatively well paid.
Wages in any given EMS market are influenced by a combination of these and other factors that are not easy to separate. Returning to the law of supply and demand, EMS leaders need to make sure their communities both demand good EMS service and are aware of the readiness costs that need to be borne somewhere.
EMS leaders also need to understand our current fee-for-service payment models are not favorable or sustainable. The resistance of many EMS providers to formal education also has a negative effect on prevailing wages. Finally, the increasing demand for EMS providers, especially paramedics, will put upward pressure on wages regardless of how more paramedics may improve or degrade an EMS system.
