Rural EMS systems face unique challenges. Poorly defined geographical boundaries, low population densities and call volumes, elongated response and transport times, the need for more well-established communication infrastructure over remote areas, and the lack of acute or specialty care facilities are all factors that impact daily operations.
I recently had the opportunity to speak with former Minnesota State EMS Director Gary Wingrove about the problems faced by rural EMS systems and potential solutions to those problems. Wingrove is the director of government relations and strategic affairs for the Mayo Clinic's nonprofit air and ground transportation company serving multiple communities in Minnesota and western Wisconsin. In 2005, he led a team of Rural EMS & Trauma Technical Assistance Center (REMSTTAC) stakeholders in developing a financial "toolkit" for rural EMS service directors. Wingrove has provided two congressional briefings and testimony, and has served on numerous state, regional and national committees. In 2004, he received the American Ambulance Association President's Award, and, in 2006, the National Organization of State Offices of Rural Health (NOSORH) Recognition Award.
What are the major issues that currently affect rural EMS systems, and did the 2006 IOM report on prehospital care spur any action in regard to these issues?
The major issues are reimbursement, recruitment and retention.
First, reimbursement. Rural ambulance services have fewer trips over which they can spread the cost of operations. Our country is still in a fee-for-service reimbursement methodology that exacerbates this problem, as it rewards those with the most transports. Compounding that problem is application of the Geographical Physician Cost Index to the Medicare ambulance fee schedule. Similar to fee-for-service, this program rewards those in high-cost areas (while the costs may be higher, opportunity volume is also higher), while further diminishing reimbursement in rural areas. Like a good safety net system should, ambulance providers organize their systems around the available reimbursement. In our case, urban areas have full-time ambulance services, provide a wide array of benefits and have buildings that look like they belong to a healthcare provider. Contrast that with rural ambulance services, which are more likely to be volunteer, provide no benefits and operate out of buildings that would be condemned in urban areas as uninhabitable.
Our counterparts in countries with different financing mechanisms, such as Canada, Australia and the United Kingdom, operate statewide/provincewide ambulance services that are all full time, provide excellent benefits and have pay scales that are in line with other healthcare professions. Are the residents of the U.S. better served? Not likely.
The Institute of Medicine got it right when they said regionalization is the way to go. The question is, how will we do it? We can examine history to answer that question: We have trauma centers (the designation of which favors urban areas—most states refuse to designate level III and IV hospitals); primary stroke hospitals (the designation of which favors urban areas—rural hospitals cannot employ the staff and provide the technology necessary to be a primary center, and there is no designation of secondary centers); and specialty hospitals like STEMI facilities (the designation of which favors urban areas and there is no designation for rural hospitals). These are not patient-centered designation systems. They create a non-system of haves and have-nots, and if we duplicate those models under the guise of the IOM recommendations, we will have missed the boat completely.
Second, recruitment. The United States has recognized, and even well documented, the issues surrounding recruitment of healthcare providers to rural areas. Unfortunately, healthcare providers in this context exclude ambulance services; EMTs and paramedics are not eligible under any of the federal programs.