Ambulance Services: Vital for public health but neglected

By Mark Whitmore, AAC Chief Legal Counsel

Ambulance services are absolutely vital. We depend on ambulance services for our own lives and the lives of our loved ones. This was true before the COVID-19 pandemic. It’s no less true in a post Covid-19 world. Yet, in the past ambulance services have been systematically disregarded by our state and federal governments.

Neglect of Ambulance Services:

Flat-line Medicaid Reimbursement Rates

On Feb. 19, 2020, the Senate and House Public Health Committees and the Senate and House Insurance and Commerce met jointly. Attendees were truly aghast about what was discovered during that joint meeting. Every Arkansan should be equally shocked.

The Medicaid reimbursement rates for advance life support (ALS) ambulance care services in Arkansas have been flat for over 25 years. ALS refers to an ambulance with a paramedic and emergency medical technician on board. Currently, every county in Arkansas has an ALS ambulance. However, that soon will no longer be the situation in Arkansas. Below is a snapshot of the funding in Arkansas over the past 26 years for ALS ambulance services and the allowable reimbursement rates under Medicaid and Medicare.

Citizens and taxpayers should be alarmed about the disregard for the funding of ambulance services in Arkansas. This systematic disregard has placed ALS ambulance services in many counties in Arkansas in jeopardy. Our class 1 and class 2 counties with populations below 10,000 and 20,000, respectively, are in the most precarious positions. Rural areas of Arkansas often lack the population and number of runs under these stagnant Medicaid reimbursement rates to keep ambulance services solvent.

Jamie Pafford-Gresham is president/chief executive officer of Pafford Emergency Medical Services (EMS), one of the oldest and largest privately-owned EMS systems in the region. She also serves as government affairs chairperson for the industry, American Ambulance Association. She explains the situation as follows:

“Historically, many counties in Arkansas contracted with private providers as not to have the financial burden and expertise required to properly staff an ambulance service 24/7/365 days a year.

In a majority of cases this was done with little to no subsidy, with providers utilizing a fee for service model to garner enough revenue to cover the cost of doing business. Today’s EMS systems are the healthcare safety net and fill the gap for proper medical coverage for many communities without local hospitals and access to healthcare clinics after hours. EMS systems across the state all participate with the Department of Health Services (DHS) Trauma System and adhere to strict guidelines for coverage and protocols required of them. Although I come from a ‘mom and pop’ ambulance service that taught me many life lessons, the days of it or a ‘mother jugs and speeds’ version of ambulance service has timed out.

Arkansas providers have worked very hard to ensure quality care across the state with access to ALS systems. This model and many of our rural providers are facing challenging times, and EMS as we know it is in severe jeopardy, and change is on the horizon.

The quality of care and the requirements of systems today have outpaced the revenue streams provided for a fee for service model. A stagnant 24-year lull in proper funding from state Medicaid, below cost reimbursement from Medicare, changes in wage and hour for providers expected to work many 24-hour shifts in a week, as well as new technology requirements and equipment costs continuing to rise has ambulance providers searching for assistance. It is not that they are bad stewards of their money, but they lack funding, and understanding of needs and support from communities in which they serve. As we move forward, a commitment from all involved to find solutions will be needed. Many in the region are realizing to ensure quality EMS, they will have to find ways to properly fund the systems in the future, making it a priority for citizens.”

Ken Kelley is the president/chief executive officer of ProMed Ambulance, a private EMS agency serving six Arkansas counties. Kelley is a past president of the Arkansas Ambulance Association (ArAA) and serves as the organization’s government affairs committee chair. Kelley adds:

“In 2020, modern EMS systems celebrate their 50th anniversary. For nearly this entire life cycle, the ArAA has stood as the recognized trade organization representing all classes of ambulance providers across the state. The ambulance industry stands strong in its traditions of innovation, flexibility and resilience. Today’s EMS agencies face new challenges in responding to time sensitive emergencies such as heart attack, stroke, trauma.”

Arkansas’ EMS providers have responded in unique ways to advance and grow the industry and the levels of care provided across the state. The ArAA has been instrumental in conducting provider education as well as community and stakeholder education. The industry has helped craft legislation such as the Municipal Ambulance Franchising Act and most recently the Medicaid Ambulance Supplemental Payment Program which, though passed in 2017, has yet to be implemented. The industry and DHS have recently re-engaged in talks that is hoped to bring about a state plan amendment that will help provide some fiscal relief.

Perry County Judge Toby Davis knows all too well the adverse impact the stagnant Medicaid reimbursement rates has had on rural Arkansas. Judge Davis testified to the legislative committees.

“Perry County is small in population, 10,455 according to the 2010 U.S. Census (ranked 63rd by population),” he said. “Perry County is 561 square miles, bordered by Conway, Faulkner, Garland, Pulaski, Saline, and Yell counties. The economic base is mostly agriculture and logging. Perry County is a rural bedroom community that consist of a lot of elderly and retired people.”

The Judge further states “The county needs to have two ambulances. When one ambulance is taking care of a call another ambulance needs to be available to respond to a second call. However, there is only enough funding and call volume to sustain one ambulance. There are several challenges in securing adequate funding for a second ambulance for the citizens of Perry County. We’ve formed an EMS Board and are looking at funding options.“

In 2015 the AAC produced the Ambulance Services Guidebook, which serves as a resource of the laws and legal authorities concerning ambulance services in Arkansas. That version was updated in 2020, and a copy is posted on the AAC website under the “Publications” tab.

Non-Emergency Transports: Act 1041 od 2019

In 2019 the General Assembly launched a task force to tackle another issue plaguing our ambulance services in Arkansas — nonemergency transports. House Bill 1710, now Act 1041 of 2019, sponsored by Rep. Mark Perry and Sen. Jimmy Hickey, Jr., seeks to address the precarious situation.

Routinely, ambulances or law enforcement vehicles are used for nonemergency behavioral health transports. EMTs, paramedics, and ALS ambulances need to be used and available to address emergency medical needs in our counties. Likewise, law enforcement officers and vehicles are finite and are needed for law enforcement emergencies. These precious resources are frequently unavailable for their intended use, due to being taken out of the county to serve as nonemergency behavioral health transportation. It’s extremely wasteful for highly trained medical staff and highly equipped ambulances to be taken offline for use in nonemergency behavioral health transports. Likewise, use of law enforcement officers and vehicles for non-emergency behavioral transports takes them out of the county and is not responsive to the public safety needs of their communities. Misdirection of these vital resources creates an unnecessary risk the lives and safety of the public.

The task force discovered several factors that must be addressed. Other states face the same issues and have initiated pilot programs. However, no state seems to have settled on definitive solutions. There are several potential and less costly recommendations to consider. One of the most interesting potential recommendations includes expansion of the state’s existing unscheduled nonemergency medical transportation model. Another model might include provision of appropriate vehicles, contracts and reimbursement rates for nonemergency behavioral health transportations by virtue of the Community Mental Health Centers (CMHCs) situated throughout Arkansas. The initial report of the task force supplied to the legislative committees is available via the link.

The Medicaid reimbursement rate for ALS ambulance services in Arkansas should be addressed and increased. Ambulance services are essential to our citizens’ health and should be treated accordingly.

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