EMS providers fret over Medicaid cuts causing collapse of system

Watertown Daily Times (NY)

Mar. 8--Emergency medical services providers are facing a crisis unlike any they have seen, which could lead to the potential collapse of the EMS system statewide, according to those in the field.

The number of certified EMS providers in the state has declined 9 percent in the last 10 years, according to a December 2019 survey titled "Where are the Emergency Medical Responders?" conducted by the state Emergency Medical Services Council. The council cites the state Department of Health Bureau of EMS.

"A substantial number of EMS agencies report an impaired ability to respond to calls for assistance due to shortages of certified EMTs and paramedics," the survey reported. "This is true for agencies that utilize volunteer responders and those that use paid responders. A majority of survey respondents had an unfavorable outlook on their agency's ability to recruit the workforce necessary to adequately serve their community."

STRUGGLES WITH RECRUITMENT

St. Lawrence County Emergency Services Director Matthew R. Denner validated the report, telling the Times that county EMS providers are having trouble getting ambulances out to service and getting enough EMTs for local departments.

"The state keeps coming up with regulations and criteria to be an EMT," Mr. Denner said. "You have to have so much training, so many hours, clinical and it is making it a lot harder for volunteers who are also trying to raise their families, full-time jobs and then trying to become an EMT on top off all of that. The requirements are quite extensive, so it's getting less appealing for our volunteers. So it is hurting all of our local departments."

Moreover, interfacility transports from local hospitals by local rescue squads can lead to trips on weekends lasting up to eight hours, if a patient needs to be taken to trauma centers out of the area. Mr. Denner said it is difficult for some agencies to find volunteers and funding for those trips.

Local volunteer rescue squads end up going to paid staff during the day on Mondays through Fridays, when most EMTs are working their full-time jobs, so the residents won't be deprived of service, Mr. Denner said.

North Country EMS Program Agency Director Ann M. Smith said providers are looking at different ways of recruitment and retention, especially in the north country.

"Many of our departments are dwindling to having very few volunteers and having to find a way to subsidize and pay somebody," she said. "We just had two departments, Hermon and Morristown, that now have a daytime EMT that never had one before because they have no one answering the calls."

The issue was recently brought before the St. Lawrence County Board of Legislators by Legislator Rita E. Curran, R-Massena.

Ms. Curran said the lack of increases in funding to EMS and cuts due to Medicaid have also created challenges that are difficult to overcome. This has increased the danger of the EMS system collapsing, following the findings of the state's Medicaid Redesign Team II, which has been tasked by Gov. Andrew M. Cuomo with cutting $2.5 billion out of the Medicaid budget.

According to a state news release regarding the redesign team, which was announced in the 2021 Executive Budget address, the team will find savings in the Medicaid program in the same way the first Medicaid Redesign Team, which he established in 2011, "set the course for recurring savings that kept the program's spending growth to less than half the national average."

The new team is tasked with developing a comprehensive set of recommendations to build on the strategy of the 2011 redesign team while identifying changes to the state's Medicaid program "that will generate $2.5 billion in recurring savings" within the 2021 state budget.

Ms. Curran said the problem is that every year the cost of providing emergency services care goes up and if there is no increase in what is getting paid for by Medicaid, providers are losing more money every year.

"So the problem has a lot do with the fact that we just don't have enough people and there is not any incentive that can be offered by the rescue squads because they're just trying to keep the doors open," she said. "The problem is that it's unconscionable to know that you are stripping the local budgets by doing this.

MEDICAID REIMBURSEMENT

Currently, when an ambulance responds to a call for a Medicaid patient, within moments of arrival, the reimbursement is spent and the Rescue Squad then starts incurring the cost, Mr. Denner said.

"The governor has his committee where he's looking over the Medicaid payout and stuff right now," Mr. Denner said. "Currently, if a volunteer ambulance pulls up on scene and somebody has Medicaid, within the first three or four seconds of the call, they have already gone over what Medicaid is going to reimburse. If you put an I.V. in a person or anything like that, you have already exceeded the reimbursement you are going to get from the insurance. So now your local ambulance services, which their budgets come out of their town, is taking that hit."

And under the new Medicaid Redesign Team, there are concerns that if those cuts come at EMS providers, it could collapse the whole system.

FEAR OF EMS COLLAPSE

Though it can't be known what the redesign team will do ahead of its reported recommendations, Gouverneur Volunteer Rescue Squad Director Mark A. Deavers said this is not the first time the state has tried to cut portions of Medicaid reimbursement.

"Last year they tried to cut different portions of our Medicaid reimbursement," Mr. Deavers said. "We were able to put some political pressure to get that changed, but this year we don't even know what to put pressure on because we don't know what the changes are going to look like.

"Depending on the size of the cuts, you're going to collapse the entire EMS system, statewide. Collapse it," he said. "Every ambulance service in New York state, even the ones that are really strong, cannot survive a massive Medicaid cut and any cut to Medicaid poses a significant risk to completely collapse the system."

He said more than 20 ambulance services have closed every year for the past three years across the state, many due to financial problems. Moreover, he said over the years, that has already occurred in St. Lawrence County, with Gouverneur Rescue Squad having absorbed Edwards Rescue Squad several years ago.

"The very simple math is, on a Medicaid patient, the first 90 seconds to two minutes of a call, the reimbursement is spent on disposables alone," Mr. Deavers said. "That doesn't count the manpower, the insurance, the vehicle maintenance and repairs, the fuel for vehicles, the light bulbs, the heat for the building, every time the bay door opens in the winter it costs $50 to back up the heat, depending on the temperature outside."

He said rescue squads, as a whole, are praying not to get a cut in Medicaid by the state as it will exacerbate the situation and close the doors of many providers, especially nonprofits and volunteer squads.

That will also have an effect on the larger services that will be expected to pick up the slack for the failing service providers, Mr. Deavers said, because that is a strain on them financially and then eventually they will also succumb to that financial strain.

Ms. Smith said in her more than 20 years in the EMS field, mostly in an administrative role, this is the worst she has seen it.

"It's disastrous. It's in crisis now," Ms. Smith said. "Cuts in funding will collapse it."

WHAT'S THE ANSWER?

Mr. Denner said the state Department of Health recognizes the issue and is working with agencies. The state is providing slight incentives, including adding $200 to your state income tax refund if you're a volunteer and tax breaks for real property if you're a volunteer.

Emergency Services is also working with the county in trying to come up with a plan to work around the struggles. However, details are scant, as Mr. Denner said they are in early talks and are looking at other counties in the state and how they have been running their programs.

Another potential assistance to agencies is the direct pay legislation that is being proposed in Albany, where insurance reimbursements will go to the provider as opposed to the patient, which is currently the case, Ms. Smith and Mr. Deavers said.

"Insurance reimbursements are sent directly to the patient and many times they Christmas shop or do something else with that money," Ms. Smith said. "That's a huge one and I know that some of the companies that have gone out of business that this is their outstanding debt, that they never get paid."

It's a bill that has been proposed for the last several years, but while the bill would be a help, the increase in Medicaid is the biggest kicker, Mr. Deavers said.

In 2017, the New York Medicaid Ambulance Adequacy Report said it was underfunding EMS by $31.4 million, he said.

"Medicaid money is matched, so $15.7 (million) is the state, $15.7 (million) is the federal, which is pennies, he said, when put up against the state budget," Mr. Deavers said.

Ms. Smith said she is trying to make communities, legislators, and municipal officials aware of the problem as the north country relies heavily on volunteers, while also trying to support them and help with recruitment and retention ideas, which could include consolidation of services.

"In this county (St. Lawrence) alone we have approximately 51 ambulances, but that doesn't mean they go out the door, so consolidation we are pushing for, but the only thing that consolidations helps is maybe the municipalities can all help pitch in a little more to cover that.

"Most of these agencies, especially the volunteer ones, they are so busy trying to figure out how to cover the cost and they don't have somebody dedicated to do the business for them, because they are all trained as clinicians, not as business people and it's not any of their fault. They are volunteering to do this," Ms. Smith said. "When push comes to shove, this ends up in the laps of the municipalities."

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