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For Rural Ambulance Providers, a Delicate Balancing Act

An ambulance is just a phone call away. But in rural parts of Colorado there’s a delicate juggling act happening before a paramedic ever gets behind the wheel. Several local governments across the state are struggling financially to keep emergency medical services on the road.

In Fort Morgan, Colo., Ambulance Service Director Joe King is faced with difficult choices every day. The operation covers 36 square miles, and only averages six calls a day. Reimbursements from Medicare, Medicaid and private insurance don’t cover its $1 million annual budget. And the county doesn’t have the money to pitch in.

King oversees a complicated billing operation as director, in addition to working full time as a medic. Last year he took on secretarial duties because the budget wouldn’t allow him to fill the position.

“Sometimes it can be overwhelming, but the way it is where we get no subsidies and we’re relying only on user fees, we had to do that,” he says.

Further south near Woodland Park, Director of Ute Pass Regional AmbulanceDistrictTim Dienst is also trying to get by with less staff. He too says reimbursements from Medicare, Medicaid and private insurance aren’t covering the bills. And he says the future doesn’t look good.

“It’s so uncertain,” he says. “We don’t know what health care reform will mean. We don’t know if we’ll see improved reimbursements, or if we will see decreased reimbursements.”

An Ongoing Battle

In rural America, low call volume, fixed overhead costs and vast geography typically translate into red ink for ambulance providers. Even in places like Utah and Colorado where state grants help, times are tough.

One hour to the east of Fort Morgan, a private ambulance service in Logan County went bankrupt. An hour to the west, Weld County transferred its service to a local medical center after writing off $4 million in uncollectable bills last year.

“It was like a big bucket of cold water being thrown in our face,” says Weld County Commissioner Sean Conway.

He says factors in the decision included a rise in uninsured patients. And even though Weld County is profiting from an oil and gas boom, it wanted out of the ambulance business.

“There are things that a hospital can do that we could not do as a county government,” he says. “A county government isn’t structured to provide health care.”

Randy Kuykendall with the National Association of State EMS Officials says local governments are faced with difficult choices every day. He explains that America has a patchwork of ambulance models run by private companies, hospitals and governments. Because it doesn’t pay to be in the rural business, the task is often left to cities and counties, which don’t have a lot of money.

“So it’s that ongoing battle of how much public support is necessary to keep that EMS system, and ultimately that health care system, in place,” he says.

Weathering the Storm

In Loveland, Thompson Valley Emergency Medical Services has had a better time at navigating the difficult funding landscape. As a health services district, it charges a 1.75 mill levy in its coverage area, which includes Loveland and Berthoud. That averages out to about $25 per year per household.

Chief Randy Lesher says forward thinking and planning has been key to the success of his district. When discussing plans several years back to build a new headquarters, the district asked voters if it could issue bonds to pay for the building instead of paying cash. That’s because the district wanted to build cash reserves to cover what it saw as increasing expenses. Medicare reimbursements were going down. Property values also appeared to be going down, and therefore mill levy payments, says Lesher.

“So us staying steady, and with some forward thinking on the rest of it, and knowing in advance what our mill levy will be, we were able to weather the storm,” says Lesher.

But while a special district provides a steady, reliable stream of funding for places like Thompson Valley, creating such a district in today’s economic climate can be challenging.

After a private ambulance service went bankrupt in Logan County, officials attempted to arrange a district there to create a steady stream of funding. Taxpayers rejected the measure, leaving the county to pick up the pieces.

The Road Ahead

If it’s not funding, Randy Kuykendall of the National Association of State EMS Officials says rural districts are struggling to recruit and train volunteers. Ambulance services in states like Wyoming are almost completely volunteer run. But Kuykendall says the median age of EMS providers is going up—not down.

“At what point do we no longer find ourselves in a position where maybe folks are willing to volunteer? And then local government is faced with how do they convert that potentially into some form of a paid system?” he says.

At Morgan County Ambulance, which switched from volunteer to paid service six years ago, Joe King is living out those challenges every day.

The county started using a modified Suburban to transport patients between hospitals about three years ago. That’s because the vehicles are more fuel efficient compared to gas guzzling ambulances.

“Last year we figured we saved $36,000 by using these for interfacility transports,” says King.

Morgan County also started a subscription service. About 500 people are paying between $35 to $50 per year. Subscribers don’t have to worry about insurance deductibles or co pays, he says.

But King says changes like these only help the service break even—not invest in the future. With population declining in many rural areas, and median age on the rise, King says both residents and elected officials need to start talking about what kind of ambulance service they want.

And, more importantly, how they’ll pay for it.

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