The Low-Pay Lowdown

The work is difficult, even backbreaking. Important, even lifesaving. So why are many EMS providers paid so shamefully little? That's a complex question. It's difficult to generalize about any industry that encompasses such a variety of setups and delivery models. EMS, depending on where you are, can be delivered by fire companies, public or private third services, even law enforcement. Providers may be full-time or part-time, paid or volunteer, unionized or not. The communities they serve may be wealthy or impoverished. Local and state governments may value and reward them, or take them for granted and ignore them. From County A to County B, conditions, problems, causes and solutions can all vary so greatly as to make broad statements impossible.

For some perspectives on this issue, EMS surveyed representatives of some of the major national EMS organizations about the causes, effects and solutions to the issue of low pay in EMS.

Causes

Why is pay so low? Some thoughts:

• We're young-"EMS is still a new profession," says John Roquemore, president of the National Association of Emergency Medical Technicians (NAEMT). "While modern EMS came about more than 30 years ago, we're still finding our place in the public safety and medical communities. We've not had the long years of establishing ourselves, and there hasn't been a unified labor movement in EMS. There hasn't been the long history of clarifying pay and benefit issues you'll find in public safety, the fire service and nursing. Those professions all have a century or more of establishing themselves."

Corresponding to that:

• Our profile is low-"I think the biggest single factor is still the lack of recognition of EMS as an essential public safety-net service," says Cai Glushak, MD, a board member for the National Association of EMS Physicians (NAEMSP). "It's still playing underdog to the fire service and police. It's still kind of the orphan child of the health system, and the personnel are therefore still undervalued."

• Supply and demand-The most basic rule of economics is that if there's a surplus of something, it can be had cheaply. Until agencies can't hire providers at what they're paying, they're not going to pay more.

"The unit cost of production is lower for producing an EMT or paramedic than it is for, say, a nurse," says Steve Hise, a program advisor with the National Association of State EMS Directors (NASEMSD). "It doesn't take as long to produce an EMT or paramedic as it does some other kinds of health professionals. Training entities are capable of producing a glut of these personnel, which contributes to keeping salaries artificially low."

• Funding disparities-Some public systems are well-funded by local governments and pay accordingly. Many are not.

"EMS funding is so varied," says Roquemore. "Some EMS organizations are supported solely on reimbursements from transports, others with a combination of tax subsidies and reimbursement. Still others are supported exclusively by tax subsidies, and some are funded solely on funds raised by bake sales and what-have-you. With changes in Medicare reimbursement, budget shortages in many state and local governments and the demands brought on by preparation for terrorism, it's difficult for many locations to address what they may perceive as shortages in EMS pay."

If subsistence is so hard for the publics, it's harder for the privates. Just recouping the costs of providing service is difficult for many; turning enough profit to actually share the wealth with providers is rare.

"Third services and privates historically don't have the government funding and backing to pay huge salaries," says Don Walsh, PhD, EMT-P, assistant deputy chief paramedic with the Chicago Fire Department and founder of International Emergency Medicine Disaster Specialists (formerly Emergency Medicine Researchers International). "If you look at the differences in pay scale between dual-role professional firefighter/EMTs and EMS providers in third-service systems, there's a huge disparity. It all ties into the economic issues private ambulance companies have been going through, like the billing factors."

Make no mistake, the Medicare reimbursement schedule is a big issue in this aspect of the discussion.

"The revenues an ambulance service generates are significantly tied to what Medicare and third-party insurers will pay," notes Hise, who has served as state EMS director for both Missouri and Arizona. "And what Medicare pays for ambulance service is also artificially low. It doesn't really take into account the cost of labor and equipment and technology and fuel and all those things."

• Perception-"EMTs and paramedics have not been given the professional status they should have," says Walsh, EMS Magazine's EMT/Paramedic of the Year for 2002. "Every time we try to fight for paramedic licensure, we get bogged down by legislatures that say, 'We can't afford to give you professional licensure, because then you can ask for higher pay and make it a labor issue.' Even firefighters are known as professionally trained firefighters. The scope of practice of paramedics is much more technical, yet we're not given that status."

Part of the perception problem may be that in so many areas, EMS is still delivered by volunteers. For that reason, some may see EMS as a less important service. After all, how important can it be if it's left to volunteers?

"You don't see volunteers in any other allied health profession, and that has to be considered when you look at EMS," says Hise. "You have to accept that volunteerism has an impact on the perception of the salary issue."

Solutions

One thing most people agree on is that before pay can improve, EMS must be recognized as essential and valued at the same level as other emergency services.

"Policymakers have to recognize that EMS performs an equal, if not greater, role as an essential public emergency service than any other out there, and that it has to be supported and valued," says Glushak. "It has to go up on the priority list of essential public safety and medical services."

A great stride toward that recognition could come with the establishment of a federal EMS office. The final report of the president's Congressional Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction, commonly known as the Gilmore Commission, recommended this, and a task force has already formed to work on making it happen (see www.projectusemsa.org). Walsh is a co-chair.

"It's going to be a federal office that can bring about administrative standards and policies for EMS in the U.S.," he says. "The first thing we have to do is recognize EMS as a vital, essential emergency service, like police and fire, and we don't have that right now. That's the first thing we have to fight for.

"One of the things we're shooting for with Project USEMSA is to have a Congressional commission investigate and identify who EMS is in the United States, its role in public safety and its role in homeland security and defense. We feel that once a Congressional commission investigates it, they're going to turn around and say, 'How have you guys been running for 30 years?!'"

For now, the answer is as mundane and unglamorous as it's always been: Work the political process. Show policymakers your value. Lobby, complain and keep the issue alive.

"EMS providers have to raise their own visibility and priority, especially to policymakers in the government," says Glushak. "They have to raise themselves as a priority for funding. The bottom line is, policymakers and government representatives still do not understand EMS."

"EMS workers need to know what's going on in their own communities, in other locations and nationally," says Roquemore. "They need to be aware of the issues that impact them. NAEMT provides a forum for EMS workers to voice their concerns and get out the message that EMS is vital and needs to be provided for. We have 10,000 members, but we need more. We need to have a powerful voice in this nation. We need to keep educating politicians, civic leaders and the public. Most people have no idea how EMS is funded and how the people who provide EMS in their community are compensated."