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COMMENTARY | Adequately staffing emergency medical services has been a problem for some time, potentially putting lives at stake. The pandemic threatens to make shortages worse.
Many emergency medical services agencies report struggling to stay adequately staffed, even as the pandemic continues to surge across the U.S. Given the life and death nature of these jobs, shortages are always serious business. But with so many health sectors now under stress, EMS leaders find it difficult to get attention for their own workforce, funding and equipment needs.
This is not a new problem. Though the pandemic has made operations increasingly difficult for EMS agencies, the National Rural Health Association two years ago published a report that cited funding and staffing problems as putting a third of rural emergency medical services in “immediate operational jeopardy.” For volunteer units, which provide service in many rural areas, volunteers are increasingly hard to come by, causing many to close.
Though the problems are particularly difficult in rural areas, city EMS services are under stress as well. In St. Louis, Missouri, for example, only 60% of the paramedic positions are currently filled. While recruiting qualified individuals for these highly demanding jobs has become increasingly difficult, keeping them on the job is even harder. “In the last two years, I hired 70 paramedics and lost 72,” says Rick Frank, personnel director for the city. “It’s a very difficult situation. We’re constantly having to train new people.” The average tenure in St. Louis dropped in the last four years from about 36 to 38 months to 24 months.
“I don’t think people have any understanding of these services,” says John Sinclair, fire chief of Kittitas Valley Fire & Rescue in Washington state, which serves a community of about 21,000 residents 60 miles east of Seattle. “They know they dial 911 and someone shows up. They don’t have a good understanding of how fragile the system is or what the needs are.”
EMS has a strange history in the U.S. While various kinds of ambulance services have existed since ancient times, coordinated emergency medical services didn’t really materialize in the United States until the 1960s. A report from the National Academy of Sciences, along with the Highway Safety Act passed by Congress, drew attention to the many lives that were lost on U.S. highways and the pressing need to get accident victims delivered quickly to hospitals.
Enthusiasm for federal funding of EMS bloomed in the late 60s and 70s, but dissolved in the federal budget-cutting 1980s. Since then, the modest federal involvement in EMS has largely been separate from other health-related endeavors, with a small U.S. Office of EMS located in the Department of Transportation and another focused exclusively on EMS for children at the U.S. Department of Health & Human Services.
The result is that EMS has become largely a local responsibility, heavily dependent on Medicare, Medicaid and private insurance reimbursement, as well as subsidized by fundraising efforts, donated labor and sometimes local tax revenues.
There is a wide variation of practices, as well as many different service delivery models. According to the National Association of State EMS Officials (NASEMSO), in Maryland, the District of Columbia and northern Virginia, the majority of 911 ambulances are fire department based. Yet, in North Dakota, out of 137 ambulance services, only one agency is part of a fire department. In other places, separate city or county units handle EMS, but sometimes it is left to hospitals or private businesses. Licensure rules, background checks and education requirements, above a national minimum, all vary, although the vast majority of states require certification of EMS workers by the National Registry of EMTs.
Shortages in the EMS workforce shouldn’t be a surprise. Remle Crowe, a research scientist and performance improvement manager at ESO, a health care and public safety software and data company, has authored or co-authored four studies about EMS worker burnout and more than a dozen others about turnover and other EMS workforce issues.
She cites low wages, limited patient outcome feedback, constant exposure to tragic situations, increasing verbal and physical attacks on EMS workers and unrelenting job demands as factors that create burned-out employees and a negative feedback loop. “Burnout increases turnover and absenteeism, which leads to increased demand on other workers, who may have to put in mandatory overtime, and that leads to more burnout,” she says.
Stresses of the job have become more acute this year. “People are questioning whether they want to do this work, put themselves on the front line and bring the virus to their families,” says John Becknell, a consultant and former editor in chief of The Journal of Emergency Medical Services.
One problem frequently cited in EMS circles is low compensation. In St. Louis, where the fire division employs both emergency medical workers and firefighters, the former are considered civilians and aren’t part of the city’s first responders. That means benefits and salary for emergency medical technicians and paramedics, who are required to have substantially more training than EMTs, are significantly lower than the firefighters they work with.
Given the extreme worker shortage and turnover problem, the city has been trying to attract paramedics with a recent hike in starting salary from $36,400 to $40,404 and a retention bonus after two years on the job. Making these kinds of adjustments are particularly difficult as St. Louis and other local governments are faced with declining revenues and many difficult budget decisions during the economic downturn.
Revenue decreases are not the only financial problem. Funding stresses have worsened as the cost of equipment increases. With fewer volunteers to help with lifting heavy people onto stretchers, for example, Kittitas Valley Fire & Rescue needed to invest in electronic stretchers, which cost $50,000 for each ambulance. Personal Protective Equipment costs soared this year. “The burn rate for PPE has gone up and the expense of the PPE has gone up tremendously. There’s a host of different effects because of Covid that in and of themselves are small, but cumulatively they do add up,” says Sinclair.
One of the chief ongoing policy issues for EMS is reimbursement, which is generally only provided by Medicare and private insurance if a patient who is picked up by an ambulance is delivered to an emergency department. This is true even if emergency medical workers are able to stabilize a patient on site and even if another alternative health care setting—like a substance abuse center—might provide more appropriate care.
There is currently a Medicare pilot that started before the coronavirus pandemic that allows reimbursement for ambulance transport to alternative locations under certain conditions, but only a small number of ambulance services are eligible to participate, according to Dia Gainor, executive director of NASEMSO. With Medicaid patients, states have the ability to take regulatory action to broaden reimbursement rules to accommodate alternative destinations or the ability to treat in place, but the majority have not done so.
Workforce and funding shortages worsened during the pandemic as training for paramedics has periodically shut down and both public and private ambulance services suffer from staff burnout, fears of contagion, and budget cutbacks. “You take this fragmented system,” says Becknell, “and you add coronavirus on top of this and it creates a difficult environment for EMS workers.”
Katherine Barrett and Richard Greene of Barrett and Greene, Inc. are columnists and senior advisers to Route Fifty.
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