BRATTLEBORO — The financial challenge facing emergency medical services, says John Vose, vice president of the Vermont Ambulance Association (VAA), lies in the moral, ethical, and legal aspects of treating emergency medical services as businesses.
“We're the last line of defense,” Vose says. “In a medical emergency, we're always going to be there whether the patient can pay or not. We're there when you need us, and we figure out the financial part later.”
The local provider, Rescue Inc., isn't alone in some of its financial difficulties, as ambulance services nationally struggle with a stark fiscal reality: the federal and state governments pay for ambulance service for citizens insured under the Medicare and Medicaid programs at rates that do not begin to approach the costs of providing those services.
Medicare, a federal program, offers health insurance to senior citizens or those with other health challenges or disabilities. Medicaid offers health benefits to low-income parents, children, seniors, and people with disabilities; that program is funded by the federal and state governments and administered by the states.
Because of the changes in population and aging of Windham County, almost 50 percent of Rescue's 4,300 responses this past year were to patients covered under the two government programs, says Mark Considine, Rescue's chief of operations.
“Medicare gives us 65 cents on the dollar, Vermont Medicaid about 35 cents on the dollar. New Hampshire Medicaid gives us even less than that,” says Linda Goss, Rescue's director of administration.
For example, Rescue charges $500 for “basic life support” service rendered, while Medicare pays only $249.32.
Furthermore, many private insurance companies have adopted the federal and state rate schedules as the basis for their payment of claims, leaving the patient to cope with increasing co-payment obligations that too often translate into bad debt for companies like Rescue.
And the government and many insurance providers will not pay for services rendered if a patient isn't transported, leaving Rescue eating its costs if its personnel respond to an accident and the victim declines a trip to the hospital.
Those shortfalls, coupled with what Goss describes as “the greater number of folks who just don't have insurance,” contributed deeply to Rescue's growing financial difficulties over the past few years.
Because such social service programs have long been budget-busters, driving state and federal budgets into the stratosphere, legislators often seek further cost savings from the programs.
Vose, administrator of Upper Valley Ambulance in Fairlee, spends a great deal of time in Montpelier as legislative liaison to the VAA when the legislature is in session. “A lot of times legislators will show up well intentioned, but they don't know the consequences for us [of a particular bill on EMS operations],” he says.
Medicare reimbursements became a more acute problem after restructuring of the rates into the form of a fee schedule that took effect in 2002. Nationwide, rates at which Medicare pays providers like Rescue have been set as one-size-fits-all categories, making allowances for designations as “rural” or “super-rural.”
EMS groups like the VAA have logged some minor victories recently.
U.S. Senator Bernie Sanders “was a cosponsor of the Medicare Ambulance Payment Extension Act, which would have increased Medicare payment rates by 5 percent for ambulatory services in 2008 and 2009 in order to extend relief to ambulance services providers,” says Sanders' Communications Director Michael Briggs.
“In the end, Congress approved a 3 percent reimbursement increase for ambulance services in rural areas,” Briggs says.
Mark Considine, Rescue's chief of operations, who maintains the service's involvement in the VAA, also notes increase in Medicaid reimbursements of 15 percent.
But further increases are unlikely at the state level, given the nature of state finances, Vose says.
“If you go up there with any proposal that costs anything, it's not even going to get looked at this biennium,” says Vose, anticipating the prospects of relief for ambulance companies within the state legislature's next two-year session. He fears current state finances might put the recent increases in jeopardy.
“Our goal is to keep what we have,” he says.