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Rural ambulance services face jeopardy as volunteers age, expenses mount

In rural America, it’s increasingly difficult for ambulance services to respond to emergencies as they struggle to find young volunteers and face financial struggles.

A Teton County, Montana, EMS volunteer wheels a stretcher into Benefis Teton Medical Center in Choteau, Montana.
A Teton County, Montana, EMS volunteer wheels a stretcher into Benefis Teton Medical Center in Choteau, Montana.
Aaron Bolton / KHN

DUTTON, Mont. — Vern Greyn was standing in the raised bucket of a tractor, trimming tree branches, when he lost his balance.

He fell 12 feet and struck his head on the concrete patio outside his house in this farming town on the central Montana plains.

Greyn, then 58, couldn’t move. His wife called 911. A volunteer emergency medical technician showed up: his own daughter-in-law Leigh.

But there was a problem. Greyn was too large for her to move. She had to call in help from the ambulance crew in the next town over.

“I laid here for a half hour or better,” Greyn said.

When help finally arrived, they loaded him into the ambulance and rushed him to the nearest hospital, where they found he had a concussion.

In rural America, it’s increasingly difficult for ambulance services to respond to emergencies like Greyn’s. One factor: Emergency medical services are struggling to find young volunteers to replace retiring EMTs. Another: There’s a growing financial crisis among rural volunteer EMS agencies. A third are at risk because they can’t cover their operating costs.

“More and more volunteer services are finding this to be untenable,” said Brock Slabach, chief operations officer of the National Rural Health Association.

Rural ambulance services rely heavily on volunteers. About 53% of rural EMS agencies are staffed by volunteers, versus 14% in urban areas, according to the NRHA. And more than 70% of those rural agencies report difficulty finding volunteers.

In Montana, the state Department of Public Health and Human Services says about 20% of EMS agencies frequently have trouble responding to 911 calls for lack of available volunteers; 34% occasionally can’t respond.

When that happens, other EMS agencies must respond, sometimes having to drive long distances, though a delay of minutes can mean life or death. Sometimes, an emergency call will go unanswered, leaving people to drive themselves to a hospital or ask neighbors.

Sixty percent of Montana’s volunteer EMTs are 40 or older, and fewer young people are stepping in to replace older volunteers.

Finding enough volunteers to fill a rural ambulance crew isn’t a new problem. In Dutton, EMS crew chief Colleen Campbell says it’s been an issue for most of the 17 years she’s volunteered.

The Dutton crew has four volunteers. In its early days, the ambulance service was locally run and survived on limited health insurance reimbursements and donations. At its lowest point, Campell said, her crew consisted of two people.

That made responding to calls, doing the administrative work and organizing the training needed to maintain certifications more than they could handle. In 2011, the Dutton ambulance service was absorbed by Teton County.

Dutton EMS Crew Chief Colleen Campbell at the Dutton ambulance barn.
Dutton EMS Crew Chief Colleen Campbell at the Dutton ambulance barn.
Aaron Bolton / KHN

That eased some of Campbell’s problems. But her biggest challenge remains finding people willing to do the 155 hours of training and take the written and practical tests in this town of fewer than 300 people.

In addition to personnel shortages, about a third of rural EMS agencies in the United States are in jeopardy because they can’t cover their costs, according to the NRHA.

Slabach said that largely stems from insufficient Medicaid and Medicare reimbursements, which, on average, cover about a third of the cost to maintain equipment, stock medications and pay for insurance and other fixed expenses.

Many rural ambulance services rely on patients’ private insurance to fill the gap. Private insurance pays considerably more than Medicaid. But, because of low call volumes, rural EMS agencies can’t always cover their bills, Slabach said.

“So it’s not possible in many cases without significant subsidies to operate an emergency service in a large area with small populations,” he said.

This all means rural parts of the country no longer can rely solely on volunteers but must find ways to convert to a paid staff.

Jim DeTienne, who recently retired as the Montana health department’s EMS and trauma systems chief, said sparsely populated counties still would need volunteers, but having at least one paid EMT could be a huge benefit.

DeTienne said EMS needs to be declared an essential service like police or fire departments. Then, counties could tax residents to pay for ambulance services.

Glacier County EMS paramedic Robert Gordon (left) and EMT Camas Rinehart put together advanced life support bags for their ambulances. Glacier EMS is one of the few paid services along Montana’s Rocky Mountain Front that responds when volunteer agencies can’t and provides advanced life support transfers from critical access hospitals to larger facilities miles away.
Glacier County EMS paramedic Robert Gordon (left) and EMT Camas Rinehart put together advanced life support bags for their ambulances. Glacier EMS is one of the few paid services along Montana’s Rocky Mountain Front that responds when volunteer agencies can’t and provides advanced life support transfers from critical access hospitals to larger facilities miles away.
Aaron Bolton / KHN

A Montana health department report suggested other ways to move away from full-volunteer services, such as having EMS agencies merge with taxpayer-funded fire departments or having hospitals take over the programs.

In the southwestern Montana town of Ennis, Madison Valley Medical Center absorbed the dwindling volunteer EMS service earlier this year.

EMS manager Nick Efta, a former volunteer, said the transition stabilized the service, which had been struggling to answer every 911 call. It recently had nine calls in 24 hours, including three transfers of patients to larger hospitals miles away.

“I think, under a volunteer model, it would be difficult to make all those calls,” Efta said.

Rich Rasmussen, president and chief executive officer of the Montana Hospital Association, said an Ennis-style takeover might not be financially viable for many of the smaller critical access hospitals that serve rural areas. Many small hospitals that take over emergency services do so at a loss, he said.

“What we need is a federal policy change which would allow critical access hospitals to be reimbursed for the cost of delivering that EMS service,” he said.

Under Medicare policy, federally designated critical access hospitals can get fully reimbursed for EMS only if there’s no other ambulance service within 35 miles, Rasmussen said. Eliminating that mileage requirement, he said, would give the hospitals an incentive to take on EMS and “dramatically improve EMS access all across this country.”

A federal Centers for Medicare & Medicaid Services pilot program is testing the elimination of mileage minimums with select critical access hospitals.

The rural EMS crunch places a greater burden on the closest urban ambulance services. Don Whalen, who manages a private EMS service in Missoula, Montana’s second-largest city, said his crews regularly respond to outlying communities 70 miles away and sometimes across the Idaho line because volunteer agencies often can’t answer emergency calls.

“We know, if we’re not going, nobody is coming for the patient because, a lot of times, we’re the last resort,” he said.

Whalen said communities need to find ways to stabilize or convert their volunteer programs, or private services like his will need financial support to keep responding in other communities.

During Montana’s legislative session this year, DeTienne pushed for a bill to study the benefit of declaring EMS an essential service, among other improvements. The bill died.

In Dutton, the EMS crew chief is thinking about her future after 17 years as a volunteer. Campbell wants to spend more time with her grandchildren, who live out of town. If she retires, there’s no guarantee somebody will replace her. She’s torn about what to do.

“My license is good until March of 2022, and we’ll just see,” she said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues.