Wisconsin Office of Rural Health paints dire picture of Wisconsin’s 911 ambulance response
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by LeAnn R. Ralph
MADISON — What are the chances that an ambulance will be able to respond if you have a medical emergency?
According to a new report from the Wisconsin Office of Rural Health, part of the UW-Madison School of Medicine and Public Health, the chances of actually having an ambulance be able to respond to your medical emergency have been steadily decreasing in recent years.
In the fall of 2022, WORH conducted an assessment concerning the reliability of Wisconsin’s 911 ambulance response.
Reliability refers to an EMS agency’s ability to send out an ambulance in response to a 911 request for service 24 hours per day.
According to state law, townships are required to provide ambulance service for town residents, but cities and villages are not required to provide an ambulance service.
Surveys were sent out to all of the Emergency Medical Services agencies in the state that provide ambulance service.
All together, out of the surveys sent to 361 agencies in Wisconsin, 216 responded to the survey, which represents a response rate of 60 percent.
Statisticians say that a response rate to a survey of 20 percent is considered quite good.
“Responses revealed that the ambulance response system in many communities is under severe strain and in critical need of immediate intervention,” according to the report.
One of the key findings of the report is that the strain on the reliability of ambulance services is state-wide but that EMS agencies in rural areas and those that rely on volunteers have the most trouble with reliability.
Another finding is that many EMS agencies do not have enough people to staff their ambulances.
All together 41 percent of the agencies reported that sections of their schedule did not have adequate staffing to respond for a request for an ambulance.
Readers should note that two EMTs are required to transport a patient on an ambulance call or one EMT and an Emergency Medical Responder (EMR), who can drive the ambulance.
The ambulance services also reported that 78 percent of the agencies had responded to another agency’s request for mutual aid because there was not enough staff at the first agency.
The lack of EMTs to respond to an ambulance call is evident also in that 41 percent of the agencies that responded to the survey reported that six or fewer staff members were providing 80 percent of the staffing hours.
A third key finding is that many EMS agencies lack the financial resources to pay their operating expenses.
Of those that responded to the survey, 29 percent said they lacked the funding to pay for their projected expenses in 2023, and 38 percent of the agencies said they were anticipating they would need to seek additional funding in the next year, such as through a referendum.
Funding challenges that were included in the survey responses referred to insufficient reimbursement from Medicare and Medicaid, limits on municipal funding (because of the state’s levy limit law), not enough sustainable funding, and increased costs caused by increasing call volumes and inflation.
The surveys reveal that 63 percent of EMS agencies using volunteer staffing, which is often the case in rural areas, reported service gaps, compared to 15 percent of the agencies using paid staff.
Agencies that use paid staff, however, reported that they are only able to provide ambulance coverage by paying large amounts of overtime.
The report includes quotes from written comments included with the surveys.
According to one quote, “Though our service strives (successfully) to maintain 24/7/365 coverage, it doesn’t come without conflict or exorbitant costs … we have had to pay extreme overtime costs and bonuses to compensate our personnel for maintaining adequate coverage.”
Of the agencies responding to the survey, 48 percent have more than one ambulance and are experiencing trouble staffing the additional ambulance.
Many service directors said they were concerned about being able to send another ambulance if the first ambulance was out and there was another emergency.
“We haven’t had gaps in coverage of the first ambulance, but we have come close. However, second calls are difficult to cover and the second emergency is just as important as the first,” according to another quote included in the report.
“We have given up over 40 calls this year because the first ambulance is busy and we are not able to completely staff the second. We would be hard-pressed Monday through Friday to staff a serious call for EMS service while the first unit is out,” according to another quote.
To staff an ambulance 24 hours per day, seven days per week, 365 days per year requires the equivalency of seven full-time employees using 24 hour shifts, according to the report.
Most ambulance services have a roster larger than seven, but many of the agencies only have a few staff members on the roster who end up covering the majority of the shifts and the calls.
If core staff ends up sick, injured or goes on vacation, that puts the agency further at risk of service outages.
According to the report, 41 percent of the EMS agencies rely on six staff members or fewer to respond to 80 percent or more of the calls received, and 21 percent rely on two or three staff members to cover the scheduled shifts.
More than half, or 55 percent, of the rural agencies rely on six or fewer staff, compared to 17 percent of urban agencies, and 62 percent of volunteer agencies rely on six or fewer staff members, compared to 16 percent of paid agencies, the report states.
According to one of the quotes included in the report, “One agency in our county has the same person running every single ambulance call they get. The minute she quits, that agency will fold up; a neighboring provider will have to come in and pick up the slack. Nobody can take on any more calls, and we are all operating at max capacity.”
Another quote states, “I try to fill as many shifts as I can and my average on call time is over 200 hours every two weeks. I also have a 75-year-old woman putting in an average of 120 to 150 hours every two weeks, which is a lot for her but we are trying to keep our ambulance afloat and doing what we can.”
When an ambulance is not available, 911 calls are rerouted to neighboring communities, and then other EMS agencies are tasked with responding to the call.
When an agency is providing mutual aid, then the agency’s home community does not have an ambulance to respond to a 911 call.
Out of the agencies that responded to the survey, 78 percent of them provided an ambulance to a neighboring agency in the past 12 months since the neighboring agency was unable to staff the primary ambulance, according to the report.
Agencies also are seeing increased call volumes.
According to a quote included in the report, “We are providing mutual aid multiple times each day. We will exceed 1,300 mutual aid calls where we responded to our neighboring services this year. Our team is tired, and our own volumes continue to go up and it is getting tougher to maintain this level because it has been nonstop since 2020.”
EMS agencies have trouble covering the schedule when staff members are volunteers and can choose when they work, since volunteer workers, even paid volunteers, cannot be compelled to work certain shifts.
The volunteers often have other full-time jobs and are not available for large parts of the day.
According to one quote in the report, “The volunteer commitment is no longer a sustainable solution to EMS staffing. We have more volunteers than before, but have less hours committed by each volunteer annually. We beg our volunteers to cover more hours, but many get frustrated and quit if we push them too hard.”
More than half of the agencies, 51 percent, have crew rosters made up of 75 percent or more who are volunteers, according to the report.
Agencies also report difficulty in recruiting new volunteers. The most reasons cited were an economy that requires people to maintain full-time jobs and the large burden of responsibility placed on EMS providers who receive no or very little compensation.
Another concern from service directors is the age of their staff members and that there will not be enough people to replace them when they retire.
According to one quote in the report, “We are finding it more and more difficult to staff our ambulance. Without our full-time paid staff, it would be impossible. Volunteers are nearly impossible to find and even finding paid staff is difficult at best. At least one of our staff is at or above retirement age. The next five years is not looking good.”
Another concern for EMS directors is the availability of training.
Out of the rural agencies that responded to the survey, 73 percent of them reported having to drive more than 30 minutes to reach the nearest training center, and several agencies said they had to drive 50 to 75 miles one way, according to the report.
Rural agencies also experience problems with classes that are cancelled when the class size is too small. Volunteer agencies have problems as well when classes are only available during the day and their volunteers are working at their day jobs.
According to one comment in the report, “We need better access to quality in-person training resources. Our closest regional training center is 50 miles from our station. That is a hurdle we can overcome but if the course does not meet minimum class size and is cancelled, we often struggle to find alternatives. Not all students are capable of online learning course work — some lack reliable Internet access at home, and others don’t thrive in the online learning environment.”
EMS agencies are different from general healthcare in that ambulance services are a function of local government, either municipal or county, while the remaining healthcare system is a function of privately-owned businesses.
Among the agencies that responded to the survey, 90 percent are receiving at least some, if not all, of their funding from their municipality, according to the report.
This means that revenue for the agency depends upon the local government’s ability to be able to find money in already-stressed budgets.
The only way municipalities can raise more money is to levy more in property taxes, except state law has a levy limit that restricts annual increases, leaving the municipality to have a referendum question asking residents for more money.
Over the past few years, reimbursements from Medicare and Medicaid have increased, and Wisconsin has increased funding to the Funding Assistance Program and has a one-time EMS Flex Grant.
The increases occurred before the surveys were sent out, so the responses received reflect the additional funds, according to the report.
Although the report does not note this, until recently, Wisconsin ranked dead last out of the 50 states for the rate of Medicare reimbursement
Nearly 30 percent of the agencies reported that their current financial resources are not sufficient to cover next year’s anticipated costs, and 38 percent reported they were planning to seek new sources of funding in the next twelve months, such as a referendum question to exceed the revenue limit, according to the report.
“We continue to have to cut replacement equipment and training out of our budget to keep up with increased ongoing staff costs, and this is just current staff, there is no way to get more staff in our restricted budget,” according to one comment.
Of the agencies that responded to the survey, 69 percent are worried they were be unable to adequately staff their primary ambulances sometime in the next year, according to the report.
“We cannot continue as we are with casual staff that do not get full-time pay and benefits. All our staff need to maintain other full-time employment. Our run volume has increased to what will be near 1,000 runs in 2022, which has significantly risen over the past several years, a large burden on casual staff that only get minimal call time and a