WINSTON COUNTY - Eric Pendley, chief operations officer of Regional Paramedical Services, recently addressed concerns that have been raised about the quality of service RPS provides in the eastern part of Winston County.
Those concerns, raised by first responders at the Arley and Addison town council meetings this month (see story page 1), are over ambulances being staffed with EMTs instead of paramedics and long response times in east Winston that result from RPS not basing ambulances in Arley or Addison.
“EMS services have EMT shortages across the state of Alabama,” Pendley said. Indeed, this is a nationwide problem. According to the American Ambulance Association, 30 percent of full-time paramedic positions, 55 percent of part-time paramedic positions, 39 percent of part-time EMT positions and 11 percent of full-time EMT positions at 119 EMS organizations surveyed were unfilled in the summer of 2022.
“Many services including RPS have utilized tiered response systems,” Pendley continued. At RPS, we utilize EMT basic units (Basic Life Support or BLS) along with advanced EMT and paramedic units (Advanced Life Support or ALS). In Winston County, we are staffing two to three ambulances a day based off peak hour workloads.” He explained there would be, on average, three trucks in the county during the peak hours of the day and two at night.
“We will have a minimum of one Paramedic truck, and the other ambulances may be an EMT Advanced or EMT Basic,” Pendley said, explaining that paramedic-staffed ambulances can carry more advanced drugs and paramedics can do more ALS procedures than EMTs of either level. “We also provide a Paramedic Intercept for those trucks,” he continued. “This is a paramedic, only, in a response vehicle that could intercept if the call needs a paramedic. Calls are triaged to see what level (of EMT) may need to respond. This enables us to staff up to three ambulances in the county at certain times.”
He said that there are always RPS ambulances assigned to Winston County. “Those trucks are staffed every day even if management must be called in to work those.” He noted, “There may be scenarios that may have both ALS units on calls already and (so) the Basic EMT truck is dispatched to initiate patient care while a paramedic is responding.”
Pendley said RPS is taking steps to correct the shortage of EMTs and paramedics. “RPS initiated an ‘earn while you learn’ program,” he said. “(We’re) basically hiring anyone interested in the medical field and training them in-house with our passionate training team to become EMTs. We opened our own training center, Regional Training Institute, in January and have full classes in EMT and EMT advanced and will start our paramedic program soon after the accreditation process is approved.”
According to its website, rpseducation.org, the institute is “a consortium” of RPS and Sumiton Fire and Rescue. The site also states that the “Regional Training Institute (RTI) EMS Education Program has an articulation agreement with Columbia Southern University (Council for Higher Education Accreditation (CHEA) accredited) to award post-secondary credits for EMS education offered by RTI upon transfer to Columbia Southern University,” which is a for-profit, online university. Right now the institute offers classes only in Birmingham, Pendley said, but it will offer virtual classes in the future.
While response times of 30-45 minutes or even an hour were cited as cause for concern by Fire Chiefs James Rickett of Arley Fire Department and Neil Feist of Helicon Fire Department at the January Arley Town Council meeting, Pendley said that the average response time for calls in Helicon during the last quarter of 2022 was 23 minutes and that the average response time for calls in both Addison and Arley was 25 minutes.
While he did not provide data for other time periods, he said the response times were always “pretty consistent” with the above averages.
“(While) you have these as an average,” he acknowledged, “you can also have (response times of) 45 minutes or longer, and those are the ones when we are responding from other locations than Double Springs.”
He said that RPS bases its ambulances in Haleyville and Double Springs, not farther east, because a majority of the calls in Winston County come from its west side. “We try to make sure we keep a truck on that side of the county at Double Springs,” he said. “Over 70 percent of the calls are on the west side, so a lot of times those trucks are there running calls. The other issue is patients being transported to Walker Baptist or Cullman Regional (hospitals). This may take a truck out of the county for an hour or two.
“We try to utilize bringing trucks up from Walker County when all trucks may be out of town, as we do post the Winston trucks to Walker if they are out of trucks and Winston County has multiple. There have been several instances (when) a Walker County truck may be posting in the county and run calls,” Pendley continued. “With rural areas and low volume, you must rely on trucks to shift from other counties to maximize the number of trucks available.”
There’s another way RPS has tried to maximize the number of available transport vehicles. “RPS also purchased an aircraft (RAMS) to help move critical patients to level one hospitals in Birmingham and Huntsville. This also aids in keeping ambulances in local areas,” Pendley said.
Number of calls
There are an average of ten calls for an ambulance a day in Winston County, Pendley said.
“The area of Arley, Addison and Helicon may generate close to two calls a day,” he said, adding, “We generally transport close to one call a day in those areas combined.”
Not all calls result in transporting a patient because some patients choose not to go to a hospital or to go in a private vehicle.
RPS transports an average of 8.2 patients a day in Winston County, Pendley said, a number that includes patients transported from one hospital to another or to another facility. He noted that on some days there might be twelve or more transports and on other days only two. “On the slow days, the third truck will help other areas or counties if needed,” he noted.
Operating costs and reimbursements
“Most EMS services will tell you that you need close to five transports a day to pay the cost of (operating) an ambulance for 24 hours,” Pendley said. “That number is rising with rising cost(s) and salaries needed to staff the ambulances.”
If five transports a day are needed to cover the cost of one ambulance, that would mean ten to fifteen transports would be needed countywide to cover the costs of the two-three ambulances RPS operates in the county. So, is RPS losing money in Winston County?
“It is a complex struggle to prevent loss and have a marginal profit for capital improvements,” Pendley said. “We have months where we take a loss in Winston County and (when) the other areas would financially support that.”
RPS receives no government subsidies and so must operate only on the fees it is paid for transporting patients. How much it is paid for a transport depends on who pays the bill. Pendley said that 65 percent of transports in all the areas where it operates are paid for by Medicare or Medicaid, while 12 percent are paid by private insurance and 10 percent by patients or indigent care. “Those numbers are very consistent across the state,” he noted.
While recent statewide data showed the average cost of responding to a call was $450, Pendley said, Medicare, having increased its reimbursement rates this year, now pays $437 for an ALS emergency transport and $275 for a non-emergency transport while Alabama Medicaid pays only $200 per transport, up from what was a reimbursement rate of $80 in the last quarter of 2021.
Similarly, transports by RAMS aircraft may be reimbursed at rates that are lower than the operation costs.
Pendley noted that the average cost of $450 for ambulance transport was an average base rate only. “ALS calls with certain procedures and long transports could raise the cost and charges (to) over $1,000. BLS cost and reimbursement can be low as $300, base rate,” he explained.
“We do get around $8 a mile from insurance providers including Medicare and now even Medicaid,” Pendley added. “Medicaid was around $4 until we got the increase in late 2021.”
He continued, “With low reimbursement from Medicaid, Medicare and indigent care, the collection (i.e., payment collected by RPS) could be as low as $400 a call. Each area is different, (depending on) the payor mix. The average commercial (i.e., private insurance) rate is close to $600, which gets services closer to the break-even margin, again depending on the payor mix of (an) area.”
The cost of responding to a call is “consistent,” Pendley said, whether or not the patient refuses transport, but RPS doesn’t get paid if there is no transport. “Fuel, payroll, wear and tear on the trucks all still have to be factored in,” even if there is no transport, he explained.
However, patients refusing transport is not as big a problem for RPS in Winston County as it could be. “Winston County has one of the higher transport averages of (the) many counties we serve,” Pendley said. He also said that the rate of refusals was “not necessarily” any higher in east Winston than west.
RPS service in Winston likely to remain the same without government funding
Still, the financial realities mean that response times in the Arley and Addison areas are not likely to change, at least not any time soon.
“We seriously understand the issue with the response times to these areas,” Pendley said. “Without additional funding to supplement trucks to that area, it would be hard to reduce the response times.”
Pendley has hope that additional funding might become a possibility at some point in the future, though. “I also serve as the president of the Alabama Association of Ambulance Services,” he said. “We have been working hard with our legislators over the last year. We had two bills pass this last session. One is the Medicaid Provider Tax program. We as an industry will tax ourselves, and the tax money will be matched by the feds close to three to one. This will bring roughly 20 million dollars of federal funds to Alabama through our Medicaid program. All the local legislators for Winston County strongly supported this bill.”
That bill was House Bill 287, passed on March 3, 2022.
“One other bill we passed was to place EMS as an essential service in Alabama,” he said. “This made (Alabama) the 22nd state to pass this, and our goal is to get this across the nation (in order) to have federal funding sent to the local governments to support EMS in rural areas like we have in Winston County.”
That bill was Senate Bill 183, passed on March 1, 2022.
“We simply must first get staffing built back up in healthcare as whole and find funding to serve all areas of the state,” Pendley continued. “I also want to assure
the communities that we are trying to do everything we can to keep response times to a minimum. We would love to be able to staff and financially support a unit stationed on (the east) side of the county. Patient care is our number one priority.”
Pendley concluded with this statement: “RPS has been one of the leaders trying to change EMS in Alabama for communities like Addison, Arley and Helicon. Rural response times are a concern here as (in) other areas across the state. We have some counties that only have one or maybe two BLS units in the whole county. I personally live close to these areas and understand the concern of waiting on ambulances. That’s why we are committed to try to find solutions across the state to help the very rural areas that may not have the volume to support the cost of an ambulance. There are calls in Jefferson County that are going unanswered, and 911 will spend long periods of time trying to find an ambulance available. The problem is worsening in higher populated areas across the state. Rep. Tim Wadsworth, Rep. Tracy Estes and Senator Garlan Gudger were all very vocal and supportive of the bills we sponsored and passed last session.”
See complete story in the Northwest Alabamian.