New Hampshire EMS Significantly Underfunded, Says State Ambulance Association

There is a threat to the availability of EMS care in New Hampshire, and the only solution is to significantly improve funding. That’s the takeaway from the report, ‘The State of Emergency in New Hampshire,’ also known as the EMS Report. Written by the New Hampshire Ambulance Association (NHAA), an organization that represents ambulance service providers in the state, the NH EMS Report is based on feedback from 147 New Hampshire sources. They include EMS and fire chiefs/agencies, hospitals, and nursing facility managers, among others.

“We are in a true state of emergency in New Hampshire and the health and safety of residents is at risk,” Justin Van Etten says, the NHAA’s Executive Director. “EMS is a critical part of the health care system and requires an in-depth review of systems and reimbursement rates if it is going to be able to continue providing necessary care to residents across the state.”

Too Many Duties, Too Little Funding

The NH EMS Report paints a picture of EMS agencies, illustrating their ongoing challenge of being asked to do too much for not enough money.

“While the [NH EMS] system was originally established to provide transportation for patients, EMS has developed over time to include delivery of healthcare and medical treatment on-site, public health and safety, and emergency response of any type,” the NH EMS Report explains.

Citing 2022 data from the New Hampshire Department of Safety, Division of Fire Standards and Training & EMS, the NH EMS Report said the 263,796 activations of the state’s EMS system resulted in 164,474 transports and 46,469 interfacility transport calls.

“Those 911 calls that do not result in transport to a medical facility are ineligible for reimbursement, despite the staff, equipment, and fuel used to answer the call,” it notes.

The takeaway: In New Hampshire, “EMS often serves as a safety net provider of pre-hospital treatment, offering care to all patients regardless of their ability to pay — or the provider’s potential to be reimbursed — for services,” the NH EMS Report explains. “Yet the pay-for-transport system remains in place, despite training for, and delivery of, far more comprehensive services. Half (52%) of survey respondents say, ‘Not being reimbursed for services provided on site is a ‘major contributor’ to the EMS challenges in New Hampshire.’”

Given this situation, 90% of the 147 NH EMS Report respondents agreed with the statement,

“New Hampshire residents’ health and safety are being impacted as a result of the EMS situation,” according to the report. 82% agreed that “The EMS system in New Hampshire is broken and needs to be revamped.” 13% say they have already experienced disruption to 911 services, and another 43% say it is fairly or very likely they’ll face 911 disruptions.

Increased Funding is the Solution

If too little money is at the heart of the NH EMS industry’s problems, then getting more money for EMS is the solution.

“What we are hearing from EMS stakeholders statewide is that reimbursement is too low across the board,” says Van Etten. “Money is so short that we’ve seen three EMS systems fail in New Hampshire since January 1st and we don't have a lot of them in this state: Three failures in a quarter is very big for us. And it’s not just a matter of being reimbursed enough money by Medicaid and private insurance companies to stay in business. The average EMT pay here is $15/hour, in an expensive state with a high cost of living. So, this is an industry that desperately needs additional funding.”

Beyond boosting reimbursement rates to allow New Hampshire EMS agencies to make a living and pay competitive wages with benefits, the NH EMS Report calls on state legislators to establish regional EMS networks to “reduce the burden on EMS providers in rural areas — or any area — and improve efficiency by absorbing ebbs and flows in call traffic,” it said.

“Additionally, expanding [or introducing] mobile integrated healthcare (MIH) is a solution that would both reduce the cost burden of unreimbursed non-transport calls and provide better holistic care to New Hampshire residents,” the report explains. “MIH has been adopted by many healthcare systems nationwide and enables efficient, targeted management of outpatient problems that would otherwise burden ambulances and emergency departments, thereby decreasing hospital admissions and improving overall patient quality of care.”

So, is more money on the way? Well, since the NH EMS Report was released, Justin Van Etten has seen positive moves by the state government and the insurance industry to raise reimbursement rates. But he is worried that the new money won’t come soon enough.

“I'm more than a little bit nervous that we will see another major EMS system fail in the next three to five months,” Van Etten says. “And I am deeply concerned that another large failure could push a region over the edge.”