The Rural EMS Crisis

     Rural EMS systems face unique challenges. Poorly defined geographical boundaries, low population densities and call volumes, elongated response and transport times, the need for more well-established communication infrastructure over remote areas, and the lack of acute or specialty care facilities are all factors that impact daily operations.

     I recently had the opportunity to speak with former Minnesota State EMS Director Gary Wingrove about the problems faced by rural EMS systems and potential solutions to those problems. Wingrove is the director of government relations and strategic affairs for the Mayo Clinic's nonprofit air and ground transportation company serving multiple communities in Minnesota and western Wisconsin. In 2005, he led a team of Rural EMS & Trauma Technical Assistance Center (REMSTTAC) stakeholders in developing a financial "toolkit" for rural EMS service directors. Wingrove has provided two congressional briefings and testimony, and has served on numerous state, regional and national committees. In 2004, he received the American Ambulance Association President's Award, and, in 2006, the National Organization of State Offices of Rural Health (NOSORH) Recognition Award.

     What are the major issues that currently affect rural EMS systems, and did the 2006 IOM report on prehospital care spur any action in regard to these issues?

     The major issues are reimbursement, recruitment and retention.

     First, reimbursement. Rural ambulance services have fewer trips over which they can spread the cost of operations. Our country is still in a fee-for-service reimbursement methodology that exacerbates this problem, as it rewards those with the most transports. Compounding that problem is application of the Geographical Physician Cost Index to the Medicare ambulance fee schedule. Similar to fee-for-service, this program rewards those in high-cost areas (while the costs may be higher, opportunity volume is also higher), while further diminishing reimbursement in rural areas. Like a good safety net system should, ambulance providers organize their systems around the available reimbursement. In our case, urban areas have full-time ambulance services, provide a wide array of benefits and have buildings that look like they belong to a healthcare provider. Contrast that with rural ambulance services, which are more likely to be volunteer, provide no benefits and operate out of buildings that would be condemned in urban areas as uninhabitable.

     Our counterparts in countries with different financing mechanisms, such as Canada, Australia and the United Kingdom, operate statewide/provincewide ambulance services that are all full time, provide excellent benefits and have pay scales that are in line with other healthcare professions. Are the residents of the U.S. better served? Not likely.

     The Institute of Medicine got it right when they said regionalization is the way to go. The question is, how will we do it? We can examine history to answer that question: We have trauma centers (the designation of which favors urban areas—most states refuse to designate level III and IV hospitals); primary stroke hospitals (the designation of which favors urban areas—rural hospitals cannot employ the staff and provide the technology necessary to be a primary center, and there is no designation of secondary centers); and specialty hospitals like STEMI facilities (the designation of which favors urban areas and there is no designation for rural hospitals). These are not patient-centered designation systems. They create a non-system of haves and have-nots, and if we duplicate those models under the guise of the IOM recommendations, we will have missed the boat completely.

     Second, recruitment. The United States has recognized, and even well documented, the issues surrounding recruitment of healthcare providers to rural areas. Unfortunately, healthcare providers in this context exclude ambulance services; EMTs and paramedics are not eligible under any of the federal programs.

     Finally, retention. What an opportunity we have to explore in EMS! The very areas of our country that have little volume and therefore could benefit from seasoned paramedics (whose backs, by the way, aren't getting any younger) can't compete to attract them. If we were appropriately regionalized (at a state level or bigger, as opposed to a multi-town or multi-county level), we could purposefully place the right provider in the right location. We might even realize a career ladder that rewards rural-ness.

     What statewide initiatives are being undertaken regarding the issues of primary concern for rural EMS systems?

     There are initiatives being undertaken by the state EMS and rural health offices of Nebraska and Minnesota (in collaboration with Nova Scotia) and another in Montana to use ambulance personnel in new ways. It is not fair to call these expanded-scope projects; they are really "expanded-role" projects. These projects would marry the emergency services role of ambulance personnel with the public health role of other healthcare workers to meet the variety of needs of rural residents and visitors. These projects are geared toward mixing ambulance and public health work with ambulance and healthcare reimbursement, a step short of a national health financing mechanism. They may allow ambulance personnel to be reimbursed under other parts of the U.S. health financing mechanism, such as home health, disease management, critical access hospital and rural health clinic funding streams. These models, if adopted in a regionalized manner, may be a buffer system between the U.S. healthcare system and those more recognized on an international level (primarily single-payer or state healthcare systems).

     With more than 75% of our nation's geography classified as rural or frontier and more than 22% of the population living in areas defined as rural, what is the future for rural EMS?

     People who live in rural areas (like I do) understand that because of population variations, we are likely to never have immediate access to cardiac cath labs, trauma surgeons and the like. Congress has recognized that there is a point at which hospitals and clinics can no longer be reimbursed using a system designed for a competitive marketplace. Congress needs to come to terms with the same realization for EMS. Rural EMS agencies, on the other hand, cannot afford to wait for Congress to act, so they must shore up their operations by becoming part of a fully functional multidisciplinary heathcare alliance that serves populations, not geography. There are gaps in our public health system; EMS agencies can use their innovation to become gap fillers. We need to learn from other countries how they are solving problems, adapt them to our own environment and financing mechanisms, and create new solutions.

     I challenge large ambulance companies that already serve both urban and rural areas to step up to the plate and adequately serve both their existing urban and rural territories. Large companies (like the one I work for) above all others serving rural areas ought to be the standard-setters in the United States, because they have the resources to move around and try innovations with minimal impact to their bottom line. Fire services, which operate a large number of rural ambulances, could realign their resources and become national EMS champions as well.

Raphael M. Barishansky, MPH, is chief of public health emergency preparedness for Prince George's County (MD) Health Department. A frequent contributor to and editorial advisory board member of EMS World Magazine, he can be reached at rbarishansky@gmail.com.