EMS DOCS’ PERSPEC TIVES ON STREET MEDICINE
Is it feasible to promise quality while slashing budgets?
By Mark E.A. Escott, MD, MPH, FACEP, NRP
Governmental entities throughout the United States continue to face tighten- ing budgets, and public safety is facing
increased scrutiny. EMS is the most vulnerable of
the three public safety services, and this vulnerability has increased over the last two decades as
large, for-profit ambulance conglomerates have
swooped in and seduced elected officials with
the promise of slashing budgets while improving quality. Sound too good to be true? That’s
because it is.
It seems counterintuitive that a private
company can replace a publicly-funded service,
decrease costs, and improve quality—while still
being able to make a sizeable profit for its executives and shareholders. Like many other sweetheart deals, to find out how this model works,
we must follow the money. Although there
are some high-quality, private, for-profit EMS
services, a disturbing pattern of behavior has
revealed itself over the last decade, and it explains
how these companies can turn a profit while
government-based services struggle.
UNDERBIDDING THE CONTRACT
The initial lure of the transition to private, for-profit EMS services is the sticker price. The
promise of a decrease in tax dollars spent, along
with the assurance of continued quality, is very
tempting for officials. Although the initial price
is attractive, there are often hidden costs and consequences. Since 2000, there have been multiple
instances where, in a effort to take over services
from a government-run EMS service, companies underbid to win the contract.
In May of 2015, a lobbyist for American Medical Response (AMR) accused
Rural/Metro, who they now own, of underbidding the contract for Santa Clara County,
stating that the company promised to be “cheaper
and faster.” 1 The result was two increases in funding for the company to the tune of $7 million—
all paid for by the county taxpayers and patients.
In a government-run EMS service, the
increased burden would be distributed among
patients, with taxpayers helping to subsidize. In
the for-profit model, the burden is often placed
on the patient.
In San Diego, underbidding combined with
increasing costs has created trouble for AMR,
the city’s contracted for-profit ambulance service. AMR will be increasing its transport fees
in San Diego to recoup these additional costs. 2
ALS transport will range from $2,396 to $2,671,
while BLS transport will cost the patient $2,022.
With Medicare reimbursement standing at $434,
the patient is left owing $1,500 to $2,000 out
of pocket. These prices, in combination with
ED and hospital bills, are a costly burden for
The other strategy to make EMS more affordable to contracting entities is to cut the costs
related to workforce and infrastructure. This
translates to significantly lower pay for private
providers compared to their public counterparts.
This can lead to increased turnover rates at
private services who often hire freshly-minted
providers at a lower pay. The providers use the
opportunity to gain experience and become more
competitive for other public safety jobs. Combined with cost savings on maintenance, fleet,
and staff accommodations, this turnover can lead
to an unfavorable work environment and concerns for patient and provider safety.
OVER-TRANSPORT & OVERBILL
A recent study sheds important light on this
long-suspected reality: There’s an increased
emphasis on billable transport, despite medical
necessity. 3 The study, which reviewed 4. 6 million 9-1-1 ambulance transports from 2009 to
2013, found that private, for-profit ambulance
services were 4. 5 times more likely to transport
patients than the government-funded cohort.
The for-profit ambulances were approxi-
mately half as likely to allow patient refusals or
treat and release options for patients. These prac-
tices, combined with larger bills, create a clear
money trail that leads to patients, Centers for
Medicare and Medicaid Services (CMS) and
private insurers creating the profit margins for
these private companies.
The study estimates that excess transports
by private providers cost the Medicare system
$25.2 million over the four-year study period.
Considering that ambulance bills may be triple the Medicare rate, the excess charge left for
consumers after coverage is likely more than
Despite significant patient financial hardships associated with many for-profit ambulance providers, the greater concern is the loss
of clinical quality. Even with mounting evidence
that response times are a blunt tool for assessing
EMS quality, the contract model often associated with these takeovers is focused on meeting
response time metrics.
For some calls, response times matter. For
every call, quality matters. JEMS
1. Kurhi E. (May 3, 2015.) Santa Clara County: $7 million in relief
sought for financially troubled ambulance provider Rural/
Metro. The Mercury News. Retrieved Dec. 4, 2017, from www.
2. Garrick D. (Nov. 5, 2017.) San Diego exploring new emergency
response model amid ambulance crisis. San Diego Union-Tribune.
Retrieved Dec. 4, 2017, from www.sandiegouniontribune.com/
3. Deziel J. Effects of emergency medical services agency ownership
status on patient transport. Prehosp Emerg Care. 2017; 21( 6):729733.
Mark E.A. Escott, MD, MPH, FACEP, NRP, is the
medical director for Austin-Travis County EMS
System. He’s also a medical director and founder
of Rice University EMS in Houston and an assis-
tant professor in the Department of Emergency
Medicine at Baylor College of Medicine. He’s the chair of the Amer-
ican College of Emergency Physicians Section of EMS and Prehos-
pital Medicine and board-certified in emergency medicine and
subspecialty board-certified in EMS.