EMS Faces Crisis With Volunteers, Training, Costs
(from Maine Townsman, March 2000)
by Steve Cartwright, Selectman, Town of Waldoboro

A generation ago, the local undertaker operated the town ambulance, and sometimes you were transported (alive) by hearse. This led to "conflict of interest" jokes.

That era of "horizontal taxicabs" has given way to trained volunteer ambulance crews. And over the years, these squads have become increasingly sophisticated; their $90,000 ambulances are practically mobile clinics.

But now emergency medical services (EMS) faces a crisis of its own. Rescue squads throughout the state are finding it next to impossible to recruit volunteers for demanding jobs. At the same time, rising costs and pressure to buy the latest in technology and training are burdening municipal budgets.

On the one hand, you hear the emotional argument: if it was you or your loved one needing help, wouldnít you want the best? On the other hand, cities and towns are finding "best" is expensive, and perhaps not the wisest use of resources. The nonprofit Windsor Ambulance Service, which serves six towns, recently had to give up its third ambulance when it couldnít afford to pay for it. The squad has 32 members, but one member said volunteering is on the way out. "Nobody can afford to volunteer."

The solution may not be simple, but some leaders believe the answer is to regionalize emergency medical services, so that resources and costs, are shared.

Jay Bradshaw, state EMS chief, said he is encouraging rescue squads to assess their needs and figure out how best to meet them. Not every service needs an extrication device, not every squad can afford its own paramedics.

Providers should focus on "being smart about the work that we do, being careful not to duplicate efforts, being careful not to re-invent the wheel. Not every town needs to have a 100-foot ladder truck if there is a good one in a nearby town," said Bradshaw, a former Belgrade selectman and current chairman of the town budget committee.

Livermore Falls Town Manager Ruth Marden thinks "regional" is the right way to go. She is looking forward to the peaceful takeover of the local ambulance service by Franklin Memorial Hospital in Farmington. "Itís hard to get volunteers, and there is the issue of Medicaid reimbursement," she said. "The hospital can get more money (from Medicaid) than our ambulance service." Livermore Fallsí share of the Community Emergency Services ó which covers that town, Livermore and Jay ó is $22,000 annually. That will be be cut to $9,000 under the hospital deal with the 20-year-old CES. Local ambulance personnel will keep their jobs, and the selectmen from the three towns unanimously support the takeover.

But finding those people hasnít been easy. "Recently, itís been almost impossible to get volunteers. Itís not just in the medical field, itís firefighters and people who used to volunteer. The whole state is suffering," Marden said.

Scott Lash, head of emergency medical services for the Town of Waldoboro, agrees. But he doesnít blame individuals for declining to volunteer. The commitment of time and even money for training, the required equipment and regulations, are a big disincentive to come forward. And, Lash pointed out, you have to be in town, within minutes of reaching the ambulance station. "You have to be in Waldoboro. If you want to go to Wal-Mart, you have to have someone cover for you."

Lash said he is grateful for his volunteers and glad that the town recently authorized paying paramedics to be on call, on a per diem basis. Before that, paramedics were paid only per call, meaning they might not be paid at all. Meanwhile, other ambulance services in the area were already paying paramedics, so the grass was greener elsewhere. For those who still volunteer, meanwhile, "itís getting to be a part-time job without pay." To fill its roster, Waldoboro has recruited eight people from Friendship and two from Warren.

Lash said Dick Hall of Hallís Funeral Home operated an ambulance for the town in the 1960s, when a new service was started, its attendants trained in First Aid. By 1974, the service included licensed emergency medical technicians, and now there are several levels of certified training among the 24-member squad, from the basic first responder to paramedic. "Itís nice to have a paramedic on every call, but itís not the paramedic alone who saves the person, itís a team effort," he said. But a paramedic can make a big difference because they are allowed to perform more complicated procedures on patients, immediately.

Having highly-trained paramedics aboard the ambulance is one of the reasons Waldoboroís EMS now has a yearly budget of $180,000. Lash expects that money to be more than replenished by a new billing policy seeking reimbursement from insurance companies and government programs. Those not covered by insurance will receive free ambulance service.

Ambulance service is never free to its providers, and not everyone is in the enviable position of Waldoboro, anticipating more revenue than expenses. The neighboring and much smaller town of Warren has contacted Waldoboro, expressing interest in a possible contract for emergency services with the larger community. Friendship, another adjacent town, could also be a candidate for a cooperative agreement, Lash said.

"Does it make sense for Friendship, with 80 calls a year, to have a $100,000 ambulance? Or Warren, with 200 calls per year?" Waldoboro averages 800 calls per year, he said. Regional pacts may be the answer to soaring costs and a shrinking pool of attendants, but there is resistance; local people like to have their own service, locally controlled. Outside contracting can be perceived as a threat to local autonomy, even if it makes economic sense.

Sharing an ambulance service has to make geographic sense. The state requires an average annual response time of 20 minutes. The Town of Unionís ambulance serves three smaller towns, too: Washington, Hope and Appleton. "The problem we have is day coverage," said Town Manager Andrew Hart. "People are out of town working." Unionís ambulance service has a $52,000 annual budget, and answers about 300 calls per year.

Hart said the member towns of the service are considering paying for paramedic coverage on a per diem basis.

Kevin McGinnis, a consultant and former state EMS chief, acknowledged that itís becoming increasingly difficult to support a volunteer ambulance service. He suggested that some communities may be raising the bar too high, trying to provide too much. One solution, used by Mid Coast Hospital in Brunswick, is to operate a paramedic "interceptor" vehicle, serving a group of area towns.

"What Iím trying to do is open peopleís eyes to see where they want their ambulance service to be in two years, EMS director Bradshaw said "the best thing we can do as a state agency is to assure that there is an EMS system to serve everyone. We canít have a paramedic on every block."