First of two parts.

FARMINGTON — 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 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 ambulance driver for Boothbay’s Simmons & Harrington funeral home in the early 1970s. “If something serious happened, the two funeral directors took care of you, because they had training in first aid and embalming.”

Former Newfield Fire Chief Richard McGlincey remembers manning the Dockendoff Funeral Home’s blue two-toned 1965 Oldsmobile hearse in the early 1970s when it was called on for ambulance duty. “You’d take the rollers out, put the stretcher in, unzip the headliner and get your beacon out,” he recalls. Giving CPR while underway wasn’t easy. “You had to jam yourself between the ceiling and the patient, brace yourself there, and try not to get knocked over.”

This began to change in the early 1970s because of a confluence of factors.

The first was an unforeseen downside of the construction of the interstate highway system. Suddenly people traveled at high speeds in the middle of nowhere in vehicles that lacked seat belts, air bags and child car seats. The number of driving deaths jumped 40 percent between 1955 and 1965 to become the leading cause of death for those under 76 years of age, with 70 percent of the deadly accidents occurring in rural areas, according to a landmark 1966 study by the U.S. Department of Transportation. Meanwhile, the study reported, many ambulance attendants had no first aid training, and the country lacked a single assembly-line manufacturer of vehicles purpose-built for ambulance services.

Meanwhile, the public was becoming aware of the incredible advances in emergency trauma and evacuation equipment and techniques developed by the military during the Korean and Vietnam conflicts. The means developed to save the lives of soldiers in Khe Sanh and Hue could be used to save those of civilians on the plains of Kansas or in the forests of Maine if properly trained and equipped medics could be stationed with or near fire crews to keep people alive until they reached the emergency room.

CONGRESS, TV SHOW HELPED CREATE EMS

Congress responded with the EMS Systems Act of 1973, which devoted $300 million (about $1.74 billion today) to help towns, counties and states design and create EMS systems, paying for equipment, expertise and training that otherwise would have been out of reach for rural communities.

Equally influential was the NBC paramedic drama “Emergency!” which aired from 1972 to 1979 and exposed the public to the lifesaving potentials of new emergency medicine techniques. Just as ABC’s “The Love Boat” gave a massive boost to the cruise ship industry, “Emergency!” prompted municipalities around the country to create paramedic departments over the next five years, expanding coverage from a handful of cities to more than half of the nation’s population.

The combination of federal resources and public enthusiasm created something miraculous: a remarkably comprehensive constellation of rural emergency medical response teams ready at the push of the magic numbers 9-1-1 to rush to people in distress, stabilize them and, if necessary, get them to the nearest emergency room. In Maine and many other states, most of these services were staffed almost entirely by volunteers, much like rural fire departments.

“Everybody had always said that a small town can’t afford to have an ambulance service, but once we showed it could work, all the neighboring towns wanted one,” recalls McGlincey, who in 1976 pushed Newfield voters to buy a used 1970 Travelall ambulance for $2,000 from the town of Rochester, New Hampshire, to start the first EMS service in interior York County. “Our first call was a snowmobile accident down in Limerick, and by the end, there was quite a crowd gathered watching us splint, package and load this guy up. Pretty soon everybody had bought a used ambulance from somewhere.”

But in 1981, the Reagan administration eliminated virtually all dedicated funds for EMS systems and replaced them with block grants for the states, which did not require any resources be dedicated to EMS. Across the country, disparities between urban and rural EMS systems began to grow, because the much lower call volumes in rural areas translated into far lower revenues to maintain the services. A 2008 National Traffic Safety Administration study found that EMS providers in rural areas – which still had to maintain rigs and personnel ready to respond at a moment’s notice – got 2,500 calls a year on average, while those in large urban centers got 42,000.

In urban areas, city governments generally filled the void left by the loss of federal funding, adding 911 rescue response units to their professional, salaried and often unionized fire departments. Cities like Portland, Lewiston, Bangor and Augusta, and their populous suburbs, have managed well because they can offer benefits and higher wages while generating decent revenue per responder and ambulance rig. Hospitals are minutes away, meaning few rigs are tied up for long.

Maine had a plan to shore up rural providers by creating regional EMS clusters and placing each under the wings of local hospitals. It fell apart, in part because of distrust between the state and the voluntary ambulance services and between the hospitals and the primary subcontractor that was supposed to set up the arrangement, according to an official 1979 Department of Health and Human Services report. “So the federal monies disappeared, the state’s plan didn’t happen, and the money that had been allocated to support the plan transitioned into the state’s General Fund,” says Jay Bradshaw, executive director of the Maine Ambulance Association in Waterville.

BETTER CARE, WORSENING ECONOMICS

Since then, many rural emergency service providers have faced a slow, steady glide toward insolvency. Their per-call operating costs are high. Their coverage areas are usually large. The economic status of their patients is weak. The towns they serve have little money to spare to fill in the gap. Equipment and training have become better and more expensive.

“We used to do the ‘scoop and swoop,’” says Cheryl Munn-Watley, a paramedic at Limerick Fire and EMS, who was first licensed in emergency medicine in 1986. “Now we have cardiac monitors with 12 leads, defibrillators, pacemakers, drugs and IVs, none of which were available then. We run codes on the scene now. It’s completely different.”

Patients benefit from being treated and stabilized before they reach the emergency room, and a lot more of them are living, which ironically increases the demands on rural ambulance services, which are then called upon to get them to advanced care facilities.

“Ten years ago, cardiac arrest patients either did well and would need to be transported or they did not and weren’t being transported anywhere” because they had died, LifeFlight’s Tom Judge says. “Now they’re being treated successfully in far greater numbers, and we’re seeing weekly calls to fly people from the small hospitals where they’ve been resuscitated to places where they can get extensive cardiac interventions.”

Some patients who are surviving have conditions so serious and specialized they can’t be treated in Boston, so LifeFlight’s aircraft have started flying patients as far as the Cleveland Clinic and North Carolina’s Duke University Medical Center, national centers of organ transplant expertise. Less severe cases typically need to be transported to the major Maine hospitals via ambulance, a trip that can take an EMS rig and crew out of their service area for an entire day, requiring another crew to be on hand to respond to the 911 dispatcher. “Despite our challenges, Maine has a really, really capable emergency care system, and that’s actually driving demand,” Judge says.

HIGHLY TRAINED, POORLY PAID

More advanced care requires emergency staff with extensive training and regular continuing education of the sort that’s nearly impossible to sustain in an all-volunteer force. A generation ago, a paramedic – the highest trained responder – needed about 500 hours of training, including clinical rotations, a load that could be managed while holding down a day job. Now it’s 1,800 hours.

There are three levels of emergency medical training, with EMTs holding basic skills. Advanced EMTs can start an IV, administer certain medications such as nitroglycerine and epinephrine, and operate advanced equipment. Paramedics can do a variety of complex lifesaving tasks: insert breathing tubes, use a needle to establish alternate airways for a suffocating patient, pump stomach contents, interpret EKGs and blood tests, and administer a variety of medicines under a remote doctor’s instructions.

“In our program, you go to school for two full years, with no summers off, to produce the quality you need,” says Eric Wellman, chairman of the emergency medical services department at Southern Maine Community College and deputy chief of the Cape Elizabeth Fire Department. “The way medicine works these days, people are sent home with a much higher acuity of illness, which means as an EMS provider you actually have to know what these different conditions are, spending time studying areas we used to never have to dig into.”

Cost is a significant factor. “The paramedic classes are scooting up to eight grand, and when you get out of there, you make $16, $17, maybe $18 an hour and are expected to be the mobile emergency room,” says Scott Lash, director of operations at Boothbay Region Ambulance Service, who serves on the Board of Occupation Safety and Health. “Because wages are so low, people work shifts in multiple places, and while they may not work more than a 24-hour shift for me, they may be coming from a long shift someplace else.” The result, he says: sleep-deprived staff and an upsurge in ambulance-caused traffic accidents.

EMS directors say recruiting and retaining EMTs and paramedics has gotten more difficult, particularly for rural services that can’t compete with city departments on wages. “When you pay just a little bit over minimum wage and you have all these requirements for an EMT to keep their license, it’s kind of hard to compete with what else is out there,” laments Eddie Moreside of Downeast EMS in Baileyville, which serves 13 towns and unorganized townships in eastern Washington County. “People say, ‘I can mow lawns for that, and I don’t have to do any continuing education hours or have to pay for a class I have to drive two hours to get to.’” Others enter nursing or other medical fields that pay more and are less dangerous.

North East pays new EMTs just $12 an hour, while a certified nursing assistant – the lowest-paid entry-level position in hospital medicine – starts at between $16 and $19.

In very rural areas, communities have relied on volunteers to staff their ambulances, but that’s become increasingly untenable, both because of the high training costs volunteers must absorb and because fewer people work in the communities where they live and hold jobs where they can just up and leave when a 911 call comes in. “A lot of people’s jobs have gotten more demanding, and they can’t just leave because usually there’s nobody to backfill for them on the cash register or at the lumber yard, because there’s a shortage of workers,” says Susi of Caribou Fire, who says the pool of volunteer EMTs in his part of Aroostook County has largely dried up.

The number of Maine students entering the basic emergency medical technician training courses has fallen by 10 percent over the past five years to around 360, according to Wellman, who estimates about 10 percent of 16 to 20 paramedics trained each year at SMCC leave the state in pursuit of higher wages. “People really want to do this work – they have an urge to help people – but when an EMT can make more at a convenience store, where the ramifications of their making a mistake don’t cost a person their life, they see that,” he says.

Eastern Maine Community College has seen a sharper decline, going from 142 basic EMT graduates to 57 over the past five years, according to data collected by Atlantic Partners EMS. The number of EMT graduates from Kennebec Valley Community College has gone from 134 to 108.

All of these problems boil down to there not being enough money, and this is primarily due to the federal government and how it compensates EMS providers who respond to calls to help people insured by Medicare, a group that makes up about half of all calls.

FIXING THE REVENUE PROBLEM

Medicare doesn’t consider EMS agencies to be health care providers, like a doctor’s office, clinic or hospital, but rather as medical suppliers. As such, they pay EMS only if they actually transported a patient for treatment, brought them to the nearest appropriate facility for their condition and an ambulance was the appropriate way to get them there. If paramedics and EMTs race to a scene of an accident, assess and treat the injured and determine that no further care is needed, Medicare pays their outfit nothing. It doesn’t pay if the patient refuses to be transported to the hospital.

“The incentives are terrible and upside down,” says Kevin McGinnis, the former state EMS director, who says 40 percent of patients seen in the field don’t need to go to the hospital. “It would be better to keep patients out of the hospital, as it’s the most expensive place to treat them, but you need to compensate EMS providers and the towns that support them for the treatment they provide.”

Even in situations where Medicare does pay, EMS providers say they still lose money on the average call, as compensation is based on mileage and the level of care required. Even the state’s largest provider, North East Mobile Health Services, which serves densely populated Greater Portland, estimates Medicare covers only 85 to 90 percent of the per-call cost.

“Super rural” ZIP codes – which constitute the majority of Piscataquis and most of the five Maine counties that share a border with Canada – get an extra 22.6 cents per mile, which helps keep them afloat, but this add-on has to be regularly reauthorized by Congress. (Maine’s senior U.S. senator, Republican Susan Collins, has been lauded by the American Ambulance Association for championing the issue and helped spearhead a five-year extension of the relevant legislation in March 2018.)

Most private insurers – whose clients account for about 10 to 15 percent of EMS call volume nationally – pattern their repayment policies on Medicare’s transport-only model, as does MaineCare, the state’s Medicaid program that insures the poor. “The only ones paying you above your cost are the private payers,” says Tristan North, senior vice president for public affairs at the American Ambulance Association, which is pushing Congress to make the “super rural” add-ons permanent, and make sure they apply to rural areas in counties that happen to border on an urban area.

Early this summer, the Maine Legislature approved a measure that boosts MaineCare rates to the Medicare level, a move EMS providers say buys a little breathing room. At legislative hearings, Med-Care Ambulance of Mexico reported the average MaineCare call in 2018 cost the service $687 to deliver but was compensated by the state at just $298, accounting for a total $198,021 in losses, or 42 percent of its operating budget. North East Mobile Health, the state’s largest provider, reported losing more than $323,000 on MaineCare transport calls last year, while the figure reported by Bangor’s Northern Light Health Medical Transport was $478,000.

“The new law makes these services run a little bit less in the red, but it doesn’t move the needle into black,” says Bradshaw, who was interim state director for EMS when the bill passed. “The problems are way more complicated, and they’re not unique to Maine.”

Taking the next step to fix the way Medicare reimburses ambulances will, unfortunately, require an act of Congress, which is deeply divided on partisan lines and embroiled in impeachment investigations. So would the creation of federal grant programs comparable to those provided to local fire and police departments. “We need to get Medicare rates up as close to cost as we can,” says AAA’s Tristan North. “But Congress is only going to raise them just so much because they have to offset that funding from somewhere.”

In February 2018, Congress passed legislation directing the government’s Center for Medicare and Medicaid Services to begin collecting accurate cost data from ambulance providers for the first time in 2020, a move celebrated by AAA because they believe it will demonstrate that current reimbursement rates are too low. The process, however, will take years to complete.

CONSOLIDATE TO LOWER COSTS

Some rural services may be able to reduce their costs by consolidating into regional providers, preferably under the auspices of a local hospital. That’s what six EMS services in Franklin County did between 2000 and 2005 when they came together to form NorthStar, a subsidiary of Franklin Memorial Hospital, which is itself part of MaineHealth. The service covers 27 towns and unorganized townships spread over 2,800 square miles of farms, towns, hills and mountains from bases in Rangeley, Phillips, Carrabassett Valley, Farmington and Livermore.

The consolidation was voluntary and driven by the local ambulance services themselves, which asked, one after another, to be absorbed under the hospital’s umbrella as costs grew, the volunteer pool shrank and low MaineCare reimbursement rates stretched them thin. “The hospital is able to help with management and facilities, and they absorb part of the administrative costs,” says Michael Senecal, the service’s director. “Just being able to manage compliance and billing and personnel involves a lot of complicated requirements that a hospital is better able to manage.”

The towns in the service area collectively make up the $1 million difference between the service’s cost ($5.2 million) and insurance and patient revenue ($4.2 million), but that is considerably less than it would cost each of them to maintain similar services otherwise. This is especially true for the towns in the Rangeley area, a remote valley pressed up on the Quebec and northern New Hampshire borders, which generates only about 400 calls a year.

Whatever reforms are implemented, it needs to happen soon, says Scott Lash of the Boothbay Region Ambulance Service.

“There’s a lot of pressure on EMS right now. The system is strained, and there are a lot of problems,” he says. “Resources are hard to come by, staffing is hard to come by, revenue is hard to come by, and services are dropping off quickly.”

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