Kentucky Counties Struggle With Ambulance Services

HARLAN, Ky. (AP) -- Dawn Nunez sat by her husband's hospital bedside, worrying that he was having a heart attack and praying he would survive the wait for an ambulance to take him to another hospital.

An agonizing 14 hours after doctors at Harlan Appalachian Regional Hospital decided he needed treatment that wasn't available locally, an ambulance finally arrived to take him to a larger hospital in Lexington, about 120 miles away.

``Time is of the essence when you're dealing with an emergency,'' Nunez said ``Even one hour is too long to wait for an ambulance. It is frightening. You just feel so helpless.''

In some of the nation's poorest counties, where many people don't have health insurance to pay for ambulance rides, the emergency transport system is spotty at best.

``Our local emergency transport system is broken,'' said Mike Layfield, chief executive officer of the small Harlan hospital. ``It's placing the health and welfare of the people at risk.''

Rural ambulance companies simply don't have the same financial base available in more populated urban areas, said Dan Summers, director of education for the Center for Rural Emergency Medicine at West Virginia University.

``First of all, they have fewer resources as far as manpower and equipment,'' Summers said. ``Population doesn't support a great deal of funding. Salaries are typically lower, so it's harder to train and retain personnel in those areas.''

The problems are widespread in rural America, and the answers are few. ``It's a tough nut to crack,'' Summers said. ``Things are considerably different in the rural setting compared to the urban setting.''

All of Kentucky's 257 licensed ambulance services deal with inadequate reimbursement of costs not just from private insurance companies but also from Medicaid and Medicare, said Charles O'Neal, deputy executive director of the Kentucky Board of Emergency Medical Services.

The effects, he said, are more noticeable in the most impoverished areas where more patients are unable to pay. That limits the number of employees working for ambulance services, prevents high salaries and makes it difficult to purchase new ambulances and equipment, O'Neal said.

A small ambulance service in Homer, La., has been forced into bankruptcy because of inadequate reimbursement. Kay Watson, who owns Claiborne Ambulance in a largely rural portion of northern Louisiana, said Medicare reimburses only about 48 percent of the cost of the average call her company makes.

That's just not enough to meet expenses in an area where many residents can't afford to pay for ambulance calls. Finances were so tight last year that employees went unpaid for about six weeks while she juggled bills to stay afloat.

``It's slow going, but we're finally getting back on track,'' Watson said. ``We had to file bankruptcy, but we're still in business.''

The federal government has been cutting Medicare and Medicaid payments to ambulance services since 1996. Watson said companies like hers have trouble shouldering the extra financial burden. For example, the cost for a 120-mile round trip to larger hospitals in Shreveport, where Homer's most critical patients are usually taken, costs an average of $800. Watson said Medicare pays about $300 of that.

The result is a lean work force - sometimes too lean, said Larry Allen, director of the Kentucky Office of Rural Health. He said local hospitals sometimes have to send registered nurses along on ambulance rides because of a lack of paramedics.

Allen said keeping the best trained staff in some of the smaller counties is difficult when they can make more money working in larger communities where reimbursement problems aren't as dire.

George Baker, owner of Mountain Emergency Medical Services in Harlan, said some physicians create the reimbursement problems when they insist on sending patients to hospitals far away when they could receive comparable treatment closer to home. Most insurance firms pay for transport to the closest facility.