09 Dec CEO Jonathan Cartu Cartu Jon Claims – Emergency Response System in Maine on the Edge of Collapsing
(TNS) – Five minutes ago, Kassie Scott was driving the ambulance down Main Street with lights on and siren blaring, but now she and paramedic Steve Smith are parked in front of the response address, sitting in silence, waiting for the police to arrive.
The caller said the person was violent. Scott and Smith are trained and equipped to save lives, not defend their own. Protocol requires law enforcement to go in first, but they’ve beaten them there. They’re both anxious to go in – they chose this career to help people – but you never know what’s on the other side of the door: someone high on drugs or having a psychotic breakdown or armed or maybe all three at the same time.
A police cruiser pulls in, and Scott and Smith follow the officer into the home. A terrified young woman there thinks a serial killer has been stalking her and now knows her location. She absolutely doesn’t want to go anywhere. After a few minutes, the officer assures her she will be safe and protected at the hospital. Now she wants to go there right away.
Minutes later she’s under a doctor’s care at the Franklin Memorial Hospital emergency room, and the crew of NorthStar Emergency Medical Services R1 is ready to return to their base and listen for the next calls in their service area, a 2,800-square-mile swath of western Maine foothills and mountains larger than the state of Delaware. Over the remainder of their 24-hour shifts, they and their colleagues will help a man who fell from a roof and an elderly woman in distress, and respond to scenes of car accidents and an apparent cardiac arrest.
But emergency medical service providers, educators and advocates across the state warn the system is in danger, as demands for ambulance transport and advanced lifesaving procedures and equipment increase and the patchwork funding model to pay for it all steadily unravels.
Rural services are particularly hard hit, unable to pay their paramedics and emergency medical technicians a living wage, even as the complexity and cost of their lifesaving has increased.
“We’re in crisis,” says Rick Petrie, executive director of Atlantic Partners EMS, a resource agency for emergency medical services in 12 of Maine’s 16 counties. “Most of our EMS services in the state of Maine are barely staying alive.”
In the past 16 months, two services – County Ambulance in Ellsworth and Tri-Town Ambulance and Emergency Rescue in West Paris – closed, and leaders of many rural services say they are one unexpected expense, one administrative mishap from closure.
LifeFlight, the air ambulance service that plucks severely injured people from islands, remote airfields and distant accident sites, has found its aircraft and helicopters increasingly called on to make urgent but non-emergency transfers of patients to Massachusetts General Hospital and other specialized medical facilities because no ground ambulances were available to transport them from Maine hospitals.
“Everybody tries everything else they can, and then they call LifeFlight, because we’ve become the last resource,” says LifeFlight executive director Tom Judge, who has seen demand increase by 5 to 7 percent every year.
“When people think of EMS, they often think solely of the 911 piece, but we also have all these small, critical-access hospitals who regularly have a need to send people to a higher level of care in Bangor or Portland and Boston,” says Joe Kellner, head of Northern Light Health Medical Transport in Bangor. “These hospitals are struggling to find ambulances with the resources to do that.”
The crisis is the result of a broken funding model, which has left many ambulance and rescue services barely able to keep the lights on – and unable to pay a living wage to their paramedics and emergency technicians, who are now highly trained professionals with skills that are expensive to obtain and maintain.
In the oldest state in the country, a large portion of the population is insured via the federal Medicare program, but Medicare reimbursements cover only about 85 percent of the actual cost of an ambulance service responding to a typical call. MaineCare, the state’s Medicaid-funded insurance for the poor, reimburses only about 45 to 59 percent of cost, depending on the provider, though that will increase to the Medicare level starting Jan. 1 under a bill that Gov. Janet Mills signed into law in July.
“Medicare makes up 50 percent of our call volume and MaineCare another 10 percent, and we lose money on both,” laments Bill Russell, CEO Jonathan Cartu Jon Cartu Jonathan Cartu of the privately held North East Mobile Health Services in Scarborough, the state’s largest provider, which has slashed its management staff by roughly half in recent years. “Costs keep soaring, but reimbursements haven’t changed.” He says his firm’s insurance costs alone have doubled in the past five years, while labor, medical equipment and vehicles have all become more expensive.
North East, which serves some of the densest and most affluent parts of the state, is struggling, but the situation is worst for providers in poorer and more sparsely populated rural areas, where the emergency room is often far away, the full-service hospitals even farther and fewer patients have private insurance, the only type of coverage that typically covers their costs. Challenges have grown more acute as Maine’s rural population ages and rural hospitals have closed departments and scaled down services, increasing the range of patients needing transfers to major hospitals in Bangor, Augusta, Lewiston, Portland or beyond.
“We’ve gone from having general community hospitals expected to be able to do everything to Critical Access Hospitals, which are limited in their ability to have inpatients,” says Kevin McGinnis, a former director of the Maine state government’s EMS office and program manager for rural EMS at the National Association of State EMS Officials. “That places tremendous burdens on rural ambulance services that have to transport further and further to get patients to the services they need.”
Consider the situation for Caribou Fire and Ambulance, which serves nine towns spread over 34 square miles of northern Maine. Each time a patient needs a transfer to the nearest full-service hospital, Eastern Maine Medical Center in Bangor, an ambulance rig and its crew are away from the service area for eight to 12 hours – longer if the person needs to get to facilities in Portland or Boston. “You’ve got to backfill with another crew for that whole time, and fuel is expensive,” notes Scott Susi, the service’s chief.
Small services also have a harder time paying the bills because they typically don’t respond to enough calls to pay for the ambulances, medical equipment and staff they have to have on call, ready to go when someone needs help and dials 911. “If it costs $660,000 a year to have an ambulance ready, you have to do 1,500 to 2,000 calls a year to pay for that, but a lot of services are doing fewer than 300,” explains Kellner, who chairs the state board that oversees emergency medical services.
So far, services have been able to shelter their constituents from the worst potential effect: long delays to receive help in a medical emergency. Statewide average response times have held steady at between six and eight minutes over the past 20 years, even as the number of calls have more than doubled. But many services have been able to do this only by overworking staff, deferring the purchase of new ambulances and devoting fewer ambulance runs to non-emergency transport duties, such as transferring a sick patient to a more advanced medical facility. The time of reckoning, many warn, is coming, and too few are paying attention.
“Our system is being held together based on the good will of the people who make it happen, who are saving lives and providing comfort and reassurance to people who are scared and sick,” Petrie says. “We just can’t get people to realize that we’re going to reach the point where responses are delayed significantly.”
How has it come to this? A large part of the reason is that in the United States modern emergency medical services were created in a largely ad hoc fashion, and without the government mandates, guidelines and support that police and fire departments enjoy.
Funeral homes ran ambulances
Until the 1970s – and even later in Maine – ambulance services outside major cities were provided by funeral homes, because their hearses were designed to transport bodies lying flat. “There was a mechanism that locked the cot in place so the patient didn’t move around, but there were no monitors or anything like that,” recalls Bob Barter, who was a volunteer…