In New York, COVID Compounds Rural Services` Struggles

Watertown Daily Times, N.Y.

The struggle for PPE, or personal protective equipment, is real, according to Mark A. Deavers, director of operations for the Gouverneur Rescue Squad. Toward the beginning of the ongoing COVID-19 pandemic, the struggle for PPE revolved around a shortage of it, but now the rising prices for these protections are adding more stress to an already struggling emergency medical services system.

PPE aside, rural EMS operations are facing a multitude of challenges that put the very future of these operations into question. From fewer volunteers to fewer calls and underfunding spanning years, rural EMS operations are in need of a change if they're to survive.

Mr. Deavers, along with Melissa Brook, also of the Gouverneur Rescue Squad, and Ann Smith, Fort Drum Regional Health Planning Organization North Country EMS Program agency director, recently co-authored an article entitled "Hard Times for Rural EMS," published by The New York State Association of Rural Health, which details some of the struggles rural operations are facing as opposed to those in more urban environments.

"Early in the pandemic, the availability of PPE was as limited as the knowledge of how the disease spread," the article reads. "Seeking medical care was thought to spread the virus, especially in confined spaces, such as an ambulance. Too afraid of contracting the disease at the hospital when they needed medical care, patients often waited until they became critical to call 911. Conditions that were treatable pre-COVID were being ignored as routine medical care came to a halt."

According to Mrs. Smith, because EMS is still considered a transport agency, they're only paid when they transport patients, yet they must respond to every 911 call.

"EMS has become healthcare, but we're still recognized as transportation and I think that's where the difficulty lies," she said Thursday. "Yes, we transport patients, but we also provide them expensive medical and clinical treatment in the back of an ambulance."

While calls are increasing once more, meaning revenue is coming in more steadily than when those who needed services were afraid to call, Mr. Deavers said the north country experienced about a 40% reduction in call volumes between mid-March and mid-May. This resulted in a like percentage of revenue reduction, while costs remained the same -- especially when "preparing for a pandemic with question marks as to what it's going to look like and skyrocketing unit price on various pieces of equipment."

In terms of PPE, prices soared. For example, a box of 50 surgical masks went from $5 or $6 a box to more than $30 a box, according to Mr. Deavers. A box of 20 N-95 masks went from about $30 a box to about $140 a box. He said most things have gone up in price, especially anything that's related to a potential COVID patient. One of the big issues he mentioned is vendors have made things non-cancelable, non-returnable, then they back order them, so EMS providers end up with a surplus of things they end up using only minimally.

EMS agencies have higher usage rates of PPE per provider than hospital staff due to not being isolated to one environment and lacking the decontamination support a health system would have the capability to provide.

According to Mr. Deavers, program revenue is currently down about $154,000. Some of this was offset through things like the Paycheck Protection Program and various other packages, but services took a great hit during COVID. Historically, he said, EMS is well underfunded. He noted that in 2016, the federal government issued a report stating 72% of nationwide responses were reimbursed at under the cost of the response.

"When you have years and years of underfunding, unexpected drops in revenue become potentially catastrophic for an entire system where you've got varying levels of financial stability of ambulance services and, as a whole, within the system it creates a lot of concern because, for various reasons, expenses have gone up and reimbursement has gone down," Mr. Deavers said. "This is the result of an underfunded system. The American Ambulance Association estimates that there's a $48,000 loss per ambulance nationwide because of the coronavirus pandemic -- and that's per vehicle -- is the way that they did their example."

Unlike hospitals, EMS agencies did not receive increased Medicare reimbursement of 20% per confirmed or presumed COVID patient to offset costs.

"Ann (Smith) and I said previously that we're one major catastrophe away from a collapsed system," Mr. Deavers said. "Unfortunately, coronavirus may actually be that catastrophe."

According to Mrs. Smith, in the tri-county area there are 79 EMS agencies overseen by her organization, 43 of which transport patients, with the remaining agencies doing first response. Overall, while it's worse in some areas than in others, she said most of the agencies are reporting a difficulty in filling open positions. This is nothing new; it was happening well before the pandemic.

An issue with other rural EMS agencies, a volunteer shortage is one of the things Mr. Deavers said hasn't affected the north country much, but the need for funding has been addressed for years with no noticeable change.

"Without a pandemic, I have concerns over the viability of the EMS system, so another wave of the pandemic could potentially be detrimental to some of our services," Mrs. Smith said. "It's important to strategically plan. I think that that's our biggest piece of advice to agencies, is to ensure that you're strategically planning and having available equipment."