Rural 911: EMS May be a Necessary Service in Illinois, but That Does Not Guarantee Such Services

Jan 1, 2013

Dr. John Warner Hospital in Clinton stopped dispatching ambulances at the end of 2012.

“The hospital decided to get out of the ambulance business because we were losing just under $600,000 a year on the operation,” says Earl Sheehy, chief executive officer of the city-owned medical facility. “It was difficult. There were a lot of emotions involved and all that.” But he says the hospital could no longer bear the financial drain. “The community can have a better ambulance service, and the hospital can be stronger without having to sustain the ambulance service.”

Rural emergency medical services across Illinois are struggling to stay afloat as the number of volunteer emergency medical technicians drops and the cost of operating the ambulances outpaces the money they bring in. 

EMS systems in states throughout the country are in reality a patchwork of local solutions. Some counties have their own ambulance services, some rely on fire departments and some count on volunteers. Hospitals often provide ambulance services, often with a mix of paid paramedics and volunteer EMTs. For-profit ambulance services have also sprung up, typically in urban areas that have enough calls to sustain profits. “Most ambulance services grew up in the local community based on local interests,” says Thomas Nehring, chair of the Rural EMS Committee for the National Association of State EMS Officials.

Jack Fleeharty, director of the Division of EMS and Highway Safety at the Illinois Department of Public Health, says Illinois reflects the diversity in EMS. “The infrastructure in EMS really varies by county — and maybe even by township — and whether it’s fire or whether it’s private or whether it is volunteer or whether it’s hospital-based,” he says. “Our state is very diverse. I mean, we have some areas where EMS providers actually compete for business, and then we have other areas where the closest EMS unit might be 20 minutes away.”

In Illinois, as in many states, EMS is not deemed an essential service, such as police and fire protection, so counties are under no statewide requirement to ensure that their residents have access to EMS. “The first 40 years, what we’ve done is we’ve proven that people like to have us around. So what are we going to do with those next 40 years?” asks George Madland, EMS systems coordinator for the Advocate Good Samaritan Hospital Emergency Medical Service System, which is based in the Chicago suburbs. “And the first thing that has to be done is [lawmakers] need to recognize us as an important essential service, just like police, just like fire — EMS. And once that happens, then other things seem to flow.” He says the designation would help to professionalize training and ensure that EMS is properly funded. “Give us the support to do it. Some of our communities are dying out there, especially in the rural areas. The people, they want the service. They want us to do it, and we need some help.”

In modern EMS services, the care does not start at the hospital but begins when EMTs or paramedics reach the patient. Offering such care is expensive, and many rural EMS operations in Illinois are struggling to stay in the black while others are closing their doors. “There’s been a number of small ambulance companies, mostly volunteer, that have gone out of business,” Fleeharty says. 

Some medical facilities, such as Dr. John Warner Hospital, which provided ambulance service for a 460-square-mile area around Clinton, are also opting out of the EMS business. Slabach says that in the past, hospitals often covered their EMS losses with money from their other revenue sources. But now, “we’re finding that hospitals are not able to sustain the losses that they are taking out of the ambulance services [with] their other operations,” he says.

In rural locales, EMS services usually cover large geographic areas while serving a small number of people. The distances they must travel can add to response times, consume gasoline and create wear and tear on vehicles. Often, the low volume of calls doesn’t bring in much money through billable services and Medicare and Medicaid reimbursements. “Even when they charge a reasonable rate, they’re only getting 40 percent of their costs in a rural area,” says Jim DeTienne, president of the National Association of State EMS Officials.

Over the years, reimbursement rates for Medicaid and Medicare have not kept pace with costs. In the 1980s, the bulk of federal funding for EMS was diverted into state grants for preventative care. “It cost us close to $600 every time we started up the engine on the ambulance,” Sheehy says. But he says reimbursements typically covered less than half of that cost. 

“When you compare the reimbursement to the cost of operations ... it is difficult to even break even,” says Greg Scott, system director for McLean County Area EMS.

An Illinois House task force has issued a report on the problems facing EMS systems in the state. One of the group’s recommendations is to find dedicated funding sources for EMS. The report suggests increasing driver’s license fees by $1. The plan also proposes directing $40 million from gambling revenues annually to EMS. The report says that such revenue should be spent on grants to EMS providers, no-interest loans for buying ambulances, grants to so-called resource hospitals that train EMTs and paramedics and increased Medicaid reimbursements for ambulance providers. 

Gilson Republican Rep. Donald Moffitt, who heads the task force, says 911 call centers need emergency funding. “Within the next year, you are going to hear about some 911 centers that are on the brink of closing.” If a center is closed, its functions fall to the Illinois State Police. Call centers for 911 are funded through a surcharge on landline phones, but as more people abandon their home lines for cells phone, the funding has shrunk. “We know some 911 call centers that are in very desperate situations,” Moffitt says. However, with many pressures on the state’s strapped budget, the politics of new state spending are difficult. 

“There’s not too much room to carve out more money from existing revenues for services that we all agree are vitally important to communities across the state. So this is just a part of that great challenge, and I think we’re going to have to look at all of those possible sources of revenue,” says Lt. Gov. Sheila Simon, who is also working on the issue through her Rural Affairs Council. Simon says she supports zero-cost solutions, such as streamlining some regulations on EMS systems. 

“We’ve kind of picked the worst time in history to try to talk about how to fund EMS,” DeTienne says. He says people do not consider whether EMS is properly funded or whether it will be there for them when they have an emergency. “They’ve just always been there, so nobody has really had to question, ‘How does this get paid for?’” 

Bradley Democratic Rep. Lisa Dugan, who was a co-chair of the task force with Moffitt, agrees that most residents just assume that an ambulance will be available if there is an emergency, and they do not question the system that makes it possible. “Many people believe it’s just there,” she says. “When a resident calls on their phone to 911, they expect somebody to answer. And when somebody answers, and they tell them they need an ambulance, they’re going to expect — and should be able to expect — that one’s going to be there, and in a timely fashion.”

In Dewitt County, where Dr. John Warner Hospital is located, voters approved a referendum in November to fund ambulance service. As of press time, the county planned to work with a private contractor to provide EMS service. “I don’t think a service could ever make it here without some kind of subsidy,” Sheehy says. 

“That’s a political thing in every county. Can you get it passed? Is that tax going to bring in enough revenue to keep that county going?” Fleeharty says. “A lot of counties have not even gone down that road.”

Another challenge for rural EMS operations is ensuring that there are trained personnel on hand to answer the call when an emergency happens. “In many of the rural areas [where EMS operations] have closed, it is because of lack of personnel,” Scott says.

Volunteers are aging. People are moving to or working in urban areas, making it inconvenient for them to volunteer for a rural service. The changing face of the country’s economy has also made it more difficult for people to volunteer. Many jobs do not offer the flexibility for workers to go off the clock for a few hours to attend to their volunteer duties if there is an emergency, and in the wake of the financial collapse, some workers are balancing multiple part-time jobs to make ends meet. Fleeharty says the days when a small-business owner, such as a local mechanic, could be on call and place a “closed for emergency” sign in the window are all but gone. “It is really changing dynamics, and certainly the economy has a lot to do with this,” he says. 

“We’ve built this system for 30 years on the shoulders of volunteers, and now we’re having a tough time trying to turn that ship,” DeTienne says. Most experts agree that the future of EMS will be a mix of paid professionals and volunteers, with the number of paid EMTs likely increasing over time. 

Moffitt says staffing issues brought the EMS problems to his attention. “A lot of the volunteer services said in their small towns, they do not have two EMTs to go on a call.” The state requires that two EMTs respond to an emergency, but the Department of Public Health is in the process of changing that requirement. Fleeharty says that services that can prove that the requirement is a hardship would be allowed to instead have one EMT respond, along with a first responder, such as a police officer. 

The task force also recommended changes to training requirements. Fleeharty says EMTs must clock 120 hours of training every four years. “That’s a lot of education for volunteers and people who maybe aren’t full-time,” he says. The report recommends that the state shift to a model that measures competency instead of focusing on hours spent in training. “Nationally, we have been moving to this competency model for education for some time,” DeTienne says. “Hours are not really supposed to be what you shoot for; it’s how you do the job.” The task force also recommends more online training to reach EMTs in rural areas. In such distance-learning scenarios, trainers would still be on hand for clinical demos. 

The task force also urges that volunteers with certified skills beyond their EMT training should be allowed to use that knowledge when responding to emergencies. Currently, they are limited to their levels of EMT training. “I talked to a solider who had served in Afghanistan and in civilian life was an EMT basic. Upon arrival in Afghanistan, he was asked to take battlefield rescue training ... and yet he cannot use those same skills in civilian life,” Moffitt says. “If it’s good enough to save a life on the battlefield, it should be good enough to save a life in civilian life.”

Dugan and Moffitt both say they hope to pass bills in the spring legislative session to address some of the problems. They are also proposing the creation of a committee and legislative caucus that focuses on EMS and fire departments. “We’re talking about the lives of people, and it’s not something that can just be put off. It’s not a Republican or a Democrat issue. It is an issue about the people of this state being able to have EMS service,” Dugan says. 


A History:

The concept of ambulance service has been with America since its early days. Belleview Hospital in New York City and New Orleans’s Charity Hospital, known first as L’Hôpital des Pauvres de la Charité, had horse-drawn ambulance service in the mid-1800s. The first volunteer rescue squads organized in the 1920s.

In the 1960s, medical innovations such as CPR, defibrillation and advances in prescription drugs gave more opportunities to make trauma treatments mobile. Veterans returning from Vietnam who went to work in emergency care had already witnessed in-the-field trauma treatment saving lives. A 1966 white paper from the National Research Council titled, “Accidental Death and Disability: The Neglected Disease of Modern Society,” sought to reduce the number of accidental deaths in the country and is cited as setting into motion the creation of the modern EMS system. Congress created minimum standards for emergency care under the National Highway Safety Act of 1966, which empowers the U.S. Department of Transportation to withhold up to 10 percent of a state’s federal highway funds if it does not comply with the standards. States also were required to create EMS systems, and the federal government provided millions in funding to support the creation of those systems.

Before those changes, the primary goal of emergency response was typically transport — getting patients to doctors who could help them. Responders might have administered some basic first aid, such as applying pressure to stop bleeding or oxygen to assist with breathing. There were no recognized standards for training or equipment. According to the National Association of Emergency Medical Technicians, at least half of the nation’s ambulance services were offered by funeral homes because they had cars on hand — either hearses or hearses converted specifically for use as ambulances — that could easily accommodate a stretcher.

Illinois Issues, January 2013