Mississippi ambulance providers fear a collapse of emergency medical services is on the horizon, partly as a result of hospitals discontinuing services and, in some cases, closing.
The crisis has caused a decline in worker availability for ambulance providers and an increase in emergency service wait times, those in the field say. And with the rise of medical costs and stagnant reimbursement rates, finances are also a challenge.
“Everything is working together and is causing this downward spiral of the whole system,” Clyde Deschamp, emergency medical service director for Mississippi Health Care Alliance, an organization aimed at coordinating medical activities within the state’s EMS districts, said. “It’s one big cycle.”
Hospital closures across the state are not only jeopardizing residents’ access to medical care but increasing interfacility transports – the transport of patients between two health care facilities.
Emergency services personnel are transporting patients longer distances due to rural hospitals no longer offering as many services. Patients now have to travel farther to get the care they need.
He said to make matters worse, once the ambulance arrives at the receiving hospital, the crew may be required to wait up to six hours in the emergency room due to bed shortages before transferring care to the hospital.
This “wall time” – the length of time emergency medical technicians and paramedics are waiting with patients before admission – prevents ambulance crews from responding to additional 911 calls, sometimes leaving a county area undercovered and residents with no assistance.
“Some of the more complicated transports won’t take just one paramedic but two. So, the problem with being stuck on the wall now is you have two people stuck waiting instead of one,” Deschamp said.
Despite the demand for workers, fewer people are pursuing this career.
According to a recent National Association of Emergency Medical Technicians report, most agencies nationwide reported increasing turnover rates on average from 8% in 2019 to 11% in 2022.
In addition, the report found from 2019 to 2022, nearly 66% of agencies experienced a decrease in job applications.
Deschamp said existing paramedics have stepped up as much as they can to fill staffing gaps, making it common for paramedics to work 80-plus hours per week.
“Unfortunately, resource management – no matter how good – simply cannot compensate for a lack of paramedics to staff ambulances and a growing demand for interfacility transports,” Deschamp told Mississippi Today. “Regrettably, the situation may get worse before it gets better.”
Gregory M. Cole, EMS advisory committee member to the Mississippi Board of Health and former chief compliance officer at Covington County Hospital, said working with limited resources to provide service in an adverse environment “is killing the morale of EMS workers.”
Cole said paramedics are burning out.
“They are exhausted,” Cole explained. “If you take a man or woman that has worked a 16-hour shift after running 12 calls, then at midnight have them take a patient six hours away. That is not safe for the patient nor is it healthy for the crew.”
At Covington County Ambulance Service, there are currently 70 employed medics and nine ambulances covering Covington, Simpson and Magee County, a roughly 1,010-square-mile area.
The ambulance service received a total of 10,000 calls last year – 90% were non-emergency and less than 10% were emergency calls. Non-emergencies included sprains and noise complaints, while emergencies included falls, motor vehicle accidents and respiratory disorders.
The number of hospital-to-hospital transfers this year for Covington County Ambulance Service as of Sept. 7 was 1,214, an increase from 714 in 2021 and 1,261 in 2022.
The rate of patient transfers spiked for two reasons, said Todd Jones, director of EMS at Covington County Hospital. The first is staff shortages at the hospitals it serves; the second is the service added Magee General Hospital and Simpson General Hospital.
In addition, the reimbursement model for EMS services is a problem, Cole said.
Cole told Mississippi Today that EMS is reimbursed at a bundled rate – it is paid an overall sum for treating a patient instead of an individualized amount for different patients.
He explained that even if he spends 12 hours taking care of a patient and $1,300 worth of medication to treat them, he is still provided one amount by the Centers for Medicare & Medicaid Services (CMS). And it usually doesn’t cover the expenses to provide emergency medical services, he said.
Cole said the uninsured, underinsured and private insurances cover only a portion of cost.
“This is equivalent to someone going into Walmart, getting $100 worth of groceries, deciding to only pay for $25 of it but still walking out with the rest of the groceries,” Cole explained. “Walmart wouldn’t allow you to do that, but somehow it’s okay to do that in ambulance services.”
Cole said without adequate reimbursement, EMS providers cannot stay response ready, attract the amount of workers they want and retain employees.
David Grayson, president of Mississippians for Emergency Medical Services, the state’s largest trade organization for ambulance personnel in Mississippi, said health insurers reimbursement rates vary by insurance type.
Nationwide, almost half of EMS patients are covered by Medicare, according to a 2008 American Ambulance Association study. The study found Medicare reimbursement rates for ambulance services are six percent less than the national average cost per ambulance transport.
In addition, uninsured patients make up an average of 14 percent of ambulance transports. Ambulance services experience almost double the uncompensated care burden as US hospitals and physicians, the study said.
Twenty to 40 percent of EMS patients are covered by Medicaid, which pays “universally low” rates.
“The concern I have is, if our reimbursements continue to stay flat or have a slow increase while our costs are obviously going up at a steeper level, then there’s going to come a time where ambulances are not going to be available,” Grayson told Mississippi Today.