Region’s ambulance operators in financial squeeze

March 22--In the Philadelphia region the business of moving patients by ambulance is on financial life support.

The industry is reeling, operators say, because of poor pay from hospitals and private health insurers, a sharp rise in Medicaid patients, and efforts to squeeze bad operators out of the business of non-emergency care.

The latest evidence of trouble, and a sign of broader industry turmoil, is the recent decision by Falck, the second-largest U.S. ambulance operator, to end operations in Pennsylvania on June 30.

"The reason we're leaving is strictly related to reimbursement. We can't make a living in the market," said Charles Maymon, regional chief executive for Falck USA, which employs about 200 in the Philadelphia region.

The area's main private insurers, Independence Blue Cross and Aetna, said they pay ambulances fair rates for non-emergency services, such as moving patients to another hospital, a rehab center, or a nursing home.

Pennsylvania Medicaid regulators said they have no money in the budget to boost Medicaid's rock-bottom ambulance reimbursement rate of $120 -- half what Medicare pays. The cost per trip is about $250, one operator said.

Medicare covers the elderly; Medicaid is for low-income individuals.

Falck, in the Philadelphia market only since 2013, has contracts for non-emergency medical transportation with Thomas Jefferson University Hospitals, Main Line Health, and Crozer-Keystone Health System.

Those systems have nearly 25 percent of beds in Southeastern Pennsylvania. Temple University Health System also uses Falck, but for a more limited scope of services.

Falck had just picked up the Main Line business on July 1 from TransCare Corp., a multi-state operator based in New York. TransCare in August abruptly ended its contract with the Cpl. Michael J. Crescenz VA Medical Center in University City.

Non-emergency ambulance services have long been an obscure corner of health care, but that is changing as evolving payment systems force hospitals to be more efficient.

"The ambulance companies get squeezed," Philadelphia health-care lawyer Alice Gosfield said. "It's a nonsustainable business model. It's not going to work, and that's why these two companies have left."

Gov. Wolf's Medicaid expansion last year, which in the Philadelphia region added more than 110,000 people to the program, exacerbated the financial distress of ambulance firms. Medicaid pays less than half the cost of a basic ambulance trip, Keystone Quality Transport said.

Complicating matters for the health systems needing to replace Falck is a moratorium by Medicare officials on new ambulance operators in the Philadelphia market, including Burlington, Camden, and Gloucester Counties. That measure was put in place to combat fraud by small ambulance operators.

Officials at the Centers for Medicare and Medicaid Services in Washington said they do not have the authority to allow exemptions to the moratorium, but will monitor the market to ensure access to services is not impaired.

Crozer and Main Line Health praised Falck, which operated in the market as LifeStar Response. "They have been a good partner and we regret that they will cease operations on June 30," Crozer said.

Jefferson officials declined to comment.

Philadelphia's VA Medical Center has used a patchwork of small ambulance companies since TransCare left, but it would like to secure a new ambulance contract, a spokeswoman said.

Ambulance contracts typically cover two pools of business, Maymon said.

One pool includes trips that are not eligible to be reimbursed by insurers. Hospital ambulance contracts usually set per-trip prices or a lump-sum payment, depending on the size of the hospital.

But for more than 90 percent of the business, Maymon said, the expectation is that Medicare, Medicaid, or insurers will pay.

Asked if Falck's bid for the Jefferson contract was too low, Maymon said it was not. "It wasn't a matter of underbidding a contract," he said.

Globally, Falck had $2.2 billion in revenue last year, but lost $77 million before taxes. The Danish company said its U.S. revenues were $340 million.

Falck won the Jefferson business from EMStar L.L.C., whose New York-based owners said they knew the Falck contract was unsustainable.

"They so undercut us that there was no way for us to even come close to it," said Daniel Herman, one of EMStar's owners.

Leaving aside how much hospitals pay for ambulances, another big problem is reimbursement from Medicaid and private insurers, operators said.

Medicare has the best rate, paying close to $240 per trip in a basic ambulance, plus $7.24 per mile..

The Medicare rate is roughly in line with costs, at least at Keystone Quality Transport Co., of Springfield, Delaware County, Keystone's chief financial officer, Todd Strine said.

In most areas of health care, private insurers commonly pay more than Medicare, but for ambulances they pay less.

At the bottom is Medicaid's $120 payment for a basic ambulance with no mileage for most trips.

Though they are not bound to the $120 state rate, according to the Pennsylvania Department of Human Resources, companies that manage Medicaid benefits, such as Health Partners Plans in Philadelphia, stick to it.

For Keystone Quality Transport, which is the biggest private operator in the region, that means "we're better off giving [the] beneficiary a $100 bill than we are taking that call," Strine said.

But Keystone cannot ignore Medicaid patients.

"We have to take those trips because the whole market would freeze up if we didn't move those patients. There are so many of them," Strine said.

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