How The Changing Healthcare System Impacts EMS-Part 2 or our Government and Elected Officials Series

This is the second part of our educational blog series for government officials. The information in these posts is looking at EMS from a general standpoint. There is no perfect formula, and there will always be variations to what I present here.

In the 1980s, I was employed at a large 700-bed hospital that also served as a level 1 trauma center. Most hospitals in my area at that time were non-profit and operated independently, although healthcare systems were beginning to form. If surgery was required, it was performed at the hospital, and patients were admitted to their rooms the night before the procedure. When someone was having a baby, they would stay in the hospital for morel than a week to ensure both mother and baby received appropriate care and monitoring. During overnight shifts in the emergency room, there were times when we would go an hour or two without seeing any patients. In most rural areas, a county hospital could handle the majority of inpatient care, only transferring patients for specialized treatment when necessary. Slowly and sometimes rapidly, things began to change. The reasons for the change are numerous and began to change the use and need for ambulances and pre-hospital care providers throughout the United States.

Consider the image of spokes in the tire below as the healthcare system in the 1980s with the spokes representing the movement of patients.

During the 1990s and 2000s, healthcare underwent significant changes as it sought new methods to provide care while adhering to government and private insurance guidelines. For instance, there were restrictions on the duration a new mother could remain in the hospital, and regulations along with insurance policies promoted decentralized care. Care systems began to evolve, leading to partnerships among hospitals, physicians, and other medical services. These changes continued to impact and challenge government entities as EMS became the entry into the healthcare system for many patients.

This image represents the complexities of patient movements that started to develop during this period.

Over the past 25 years, the healthcare system has both decentralized and consolidated, affecting the type and amount of ambulance transport needed. Now there are medical clinics, standalone ERs, Cardiac Catheterization Labs, outpatient surgery centers, rehab centers, hospice facilities, and skilled nursing facilities to name just a few. In rural areas, many hospitals have become critical access hospitals, offering only emergency room services and observation stays. Obstetrics in rural hospitals is rare, and patients with serious trauma must be transferred to higher-level centers. When the pandemic hit, these challenges became even clearer, as staffing shortages forced hospitals to consolidate certain services, like MRI testing, to a single facility within their system. All these changes happened without considering the crucial element that keeps the system moving—the spokes!

The current depiction of patient movement.

Ambulance transportation and response generally fall into three main categories. The first is responding to 911 calls for medical emergencies, which serves as the ultimate safety net for anyone in need. While vital, it’s also the most expensive and least cost-effective from a business perspective, since it requires constant staffing and equipment readiness. Achieving cost neutrality with this type of service is rare, so officials should be cautious of claims suggesting otherwise. The second category is transferring patients between medical facilities when their care needs can’t be met at their current location. These transfers are often medically complex and require paramedic-level expertise. The third involves less intensive care, where patients are transported with EMT or paramedic monitoring from hospitals to other settings because they are not able to sit or ambulate. These are usually more predictable, making them easier to manage with a business-oriented staffing model.

In part 1, we covered the many delivery models for ambulance transport and pre-hospital care. The main point here is that it’s not as simple as just looking at the numbers. While it might seem reasonable to say an agency will only handle 911 calls, the reality of today’s healthcare system makes that tough. Most larger communities have several clinics, outpatient surgery centers, and nursing care facilities. When a patient needs care beyond what those places can provide, they call 911. In essence, 911 ambulance services act as the emergency response team for their area, no matter the type of facility.

It’s possible for ambulance transportation to be cost positive in certain situations, but it requires treating it like a business model that includes all types of transports. The challenge is that you can’t staff for 911 emergencies and expect the same resources to handle other transport needs.

The healthcare system has been continuously adjusting to stay financially sustainable while still providing quality care. Many of these changes have pushed costs onto local governments through increased EMS call volumes, and very little increase in reimbursement. Even some of the most efficient systems in the U.S. now require government funding to keep running. Leading industry groups like the American Ambulance Association, National Association of Emergency Medical Technicians, and National Association of EMS Physicians are actively advocating for better reimbursement and broader systemic reforms.

The initial graphic illustrates the various aspects of EMS and shows the interactions with healthcare which leads to the debate over whether we belong to healthcare or public safety. In part 3 of our series, we will further explore the background by addressing questions you might encounter about billing rates and reimbursement, as well as why billing is necessary when taxes are already being paid.

Upcoming Posts

Part 3 will cover how ambulance service charges are determined and why costs can vary significantly between providers.

Other Future Topics

Why measuring response times as a key metric for 911 quality is changing and how that change is positive for government agencies.

Staffing models and key considerations for both personnel and shift types.

Ambulance service accreditation—and why it’s worth considering.