Thatâs the word Luke DeRosa, operations chief and director of human resources for Noga EMS, used to describe the emergency management services situation in Pennsylvania.
Personnel shortages, budgetary restrictions and a job that constantly evolves have combined to hamstring the ability of both Noga and MedEvac, the two private ambulance companies that serve Lawrence County.
For the first time since 2004, Pennsylvania has passed legislature to raise the reimbursement rates for Medicaid recipients. The rate for Basic Life Support has gone from $120 to $180, and the rate for Advanced Life Support has gone from $200 to âno less thanâ $300. In November, the state also passed legislation requiring reimbursement for non-transport calls.
These changes are set to begin in 2019. However, in the 14 years between rate changes, the business of ambulances service has gotten very expensive.
âWhen you look at a company like FedEx, or like UPS, that is in transport, what happens when the price of gas goes up? Your shipping cost goes up. We donât get that,â DeRosa said.
Ed Heltman, president of MedEvac, said the low medicaid reimbursement has been especially hard on the companies in Lawrence County due to the countyâs demographics.
According to the US Census Bureau, 21.9 percent of Lawrence County is older than 65 and 12.4 percent of the population is under 65 and living with a disability.
âWeâre a private company,â Heltman said. âWe can charge whatever we want, but there is a cap on what we can receive from those who receive medical assistance. When it comes to the insurance companies, they essentially said âif itâs good enough for them, itâs good enough for us.
âI started my company in 1990. If I transported four patients in a day, it didnât matter if it was emergency or non-emergency, but transporting those four patients would cover the cost of running that ambulance for 24 hours. With todayâs reimbursement rates, in that same 24-hour period for that one ambulance, itâs going to take approximately 12 transports.â
Ensuring payment at the time of a call is out of the question.
âWe canât ask when someone calls in â nor would we ever â if theyâre a Medicaid recipient or not,â DeRosa said. âWe lay out our services and our labor before we get paid with no guarantee of ever getting that investment back.â
In 2005, the National Registry of Emergency Medical Technicians became the sole provider of certification at one or more levels in 46 states â including Pennsylvania.
âOn paper, a national curriculum sounds like a good idea,â DeRosa said. âItâs just made the process of getting certified more cumbersome, more difficult. Some of the things required in the curriculum never come up in the field. The National Registry has a lot of physicians on the board, and they have this altruistic view of what EMS should be. The reality is that we are not using that.
âWe used to have a place in Lawrence County where you could become a paramedic. We havenât for five years. Now, you have to go to Indiana, PA, or Erie or Pitt. When I became a paramedic, it was taught at our local vocational school. It was Tuesdays and Thursdays for 12 months with one Saturday a month, and it cost about $900.â
Now, DeRosa, would-be paramedics are looking at a full-time commitment as a student to earn an associate degree.
âAt that point,â he said, âno one is becoming an EMT, because you become an EMT to become a paramedic. With the work it takes to become a paramedic, people are just going to nursing school instead.â
The progression to paramedic within the national registry, DeRosa said, starts with 50 hours of training to become an emergency medical responder.
The next step in advancing in the field is becoming an EMT-B, or a basic emergency medical technician. According to Unitek EMT, an EMT training school in California, an EMT-B has about 110 hours of training. An EMT-Bâs duties include providing basic life-support functions and performing non-invasive procedures.
After 150 to 200 hours of training, one can advance to become and EMT-A, or advanced emergency medical technician. Then, a person can become a paramedic, which requires about 1,000 hours of training and education.
âThis is how convoluted this gets,â DeRosa said. âAn EMR and an EMT can ride in the ambulance together, with the EMR driving. Two EMTs can ride in an ambulance together. But, an EMR and a paramedic cannot ride together.
âIâm a paramedic, so I can do anything I need to do while out in the field. If I am treating someone, however, and want to take them to UPMC Jameson, I need an EMT to drive us. It canât be an EMR, even though itâs just a person driving. It would be great if I could get a volunteer firefighter to drive with me in the back. We have had retired police officers and firefighters ask if they can help drive the ambulance. They would be great at it, they drove emergency vehicles for their entire careers. But, we have to tell them they need to go become EMTs.â
Even combat veterans canât get help without EMT training.
âLetâs say you have military service, and you served in a combat zone,â DeRosa said. âYouâre able to apply tourniquets, insert IVs, and control bleeding. You did this while under fire in an active combat zone. Those are all things a paramedic has to do, an EMT canât. You come to us and we canât hire this person as a paramedic yet because he has to go take the classes.â
The trend toward regionalization of health care also takes its toll on ambulance services, as some patients now must be transported out of the county to receive the care they need.
âOne thing that has really taxed us is that there is no inpatient psychiatric care here,â DeRosa said. âWe used to transport patients to the old Jameson South. Now, weâre required to take them to Pittsburgh. Thatâs a big difference from being a mile down the road and staying within the community and being available (for other calls),â DeRosa said.
DeRosa sees the recently passed legislation to provide reimbursement for non-transport calls providing a measure of relief. Such calls â particularly those involving overdoses â have increased drastically, he said.
âWith the opioid epidemic, we will provide life-saving care. We will administer a NARCAN, and they will refuse to be transported,â he noted, adding that diabetics can create similar situations when their sugar drops.
âWe have a drug called D50, so we can immediately reverse that. The patient wakes up. We make sure theyâre OK. We call a physician, we talk with the patient and the physician. We make sure they have something to eat, thereâs someone there and theyâre in a safe environment. Thereâs no need to take them anywhere, so they sign a refusal and thatâs it. We have never gotten reimbursement for that.â
DeRosa said he national registry âhas not workedâ and he would like to see the return of local, low-cost EMS training to the area.
He also believes that contracts with municipalities are in order, though it would require the support of all of the municipalities in the county. He has proposals in place, and is hopeful that the municipalities will reach out.
Heltman believes that the recently passed legislation is a positive step toward returning the EMS field to a more level state. He said that MedEvac has started training EMTs in-house again for the first time this year. He believes this is a good way to get EMS workers trained, and cited a program in Fayette County where an EMS agency would hire people off-the-street with no experience and paid them minimum wage to go to an EMT program with the guarantee of a job if the person graduates the program.