FredG

Thanks! I kinda figured it had to do with the govt payout on calls, but your explanation was great.

Thanks guys! When I worked their calculations backwards (they never actually put it on paper, but did discuss transports, mileage, and potential billing rates), their estimated yearly revenue based on our transport volume works out to about 80% of the potential billed calls. Looking further into this, it also appears they are basing potential revenue on an average call having 20-25 loaded miles at $15 per loaded mile. The problem with that is the nearest community hospital is just under 9 miles from the centerpoint of the coverage area. The nearest hospital in county is closer to 20 miles, but 90+% go to the closer one. They claim they rarely go to collections, usually only when they know the insurance company paid the patient and the patient did not send in payment. CrotchityMedic1986, you mentioned mandatory write-offs. Can you explain further? The last time I worked for a service that billed was about 7 years ago, so I know I'm out of the loop, but I want to make sure I understand what transports may be written off. Also, this is a 911 service with the very rare interfacility when a commercial service can't come down out of the city(maybe 3-4 a year).

I recently met with a third-party billing company that claims over 80% financial return rate with their current clients, with some as high as 87%. My research pegs the average at closer to 58%. I am wondering what is considered a good collection rate for a rural area. Yes, this company did provide some references, but the 80+% rate just seems too high compared to the averages I have read about and experienced in the past with other departments. It just doesn't "feel right". I will be contacting some of their references and talking to other 3rd party billers. As a backgrounder, my department is volunteer and rural with about 400 calls (240 or so transports) and a part of the local VFD. State law does not allow our type of department to bill, but we are looking at options to possibly split off from the FD down the road and billing/revenue is a piece of the puzzle. My department is trying to get all of our ducks in a row before we pursue any specific course of action. TIA

Dispatched using EMD trained call takers and dispatchers, run by the county. the quality of dispatch triage is a whole different topic, but regardless of the quality of any EMD protocol, they are the ones that make the initial assessment and assign an initial priority. In an ideal situation, we all would have all ALS units with all EMS professionals making a living wage. But, each area has it's own challenges and needs. My county is about the size of Rhode Island and aside from one small city, the rest of the region is covered by 2 medic fly cars with a single medic each and 19 volunteer BLS transporting agencies. We had a 3rd ALS fly car, but R/M decided it was not profitable and got the county to approve dropping the unit a few years ago. So, I do not see how this is redundant. I know that R/M has to maximize profits, but if their 3rd fly car could not be profitable when they only pay their medics about $12/hr in this region, then how can the volunteer squads justify staffing their 19 ambulances with 2 staff each? And again, I cannot justify spending 2+ years in the process to get my department to the point where it would be allowed to bill for ambulance service and become paid just to get some low paying EMS jobs in the area. On my other volunteer position, on the board of Directors for a Local Development Corp, we are trying to bring in businesses and jobs that build wealth and will bring our area's recent grads back into the area for employment. $8/hr jobs simply don't do that and will not improve the quality of life. If I could see a way to start EMTs in this area around $14+/hr, then I would have a different opinion. But, I know the political players and I know the budgets. Even crunching the numbers with a 40% payment rate (which IMO is high for most any 911 unit), there is not enough funds to subsidize EMS service with salaries even below minimum wage. Raising taxes is not a viable answer either as property tax increases are limited to a small percentage by state law. Going to a pay per call system is one option, but that is only a stopgap between volunteer and paid and does not help improve EMS salaries anywhere.

I can honestly say that I have never "saved" a paramedic. There have been times that I pointed out something or identified issues found on a secondary assessment that made the paramedic change his treatment, but that is part of being a team. There is only one instance, about 10 years ago, that I ever wrote up a paramedic partner for a patient care issue. We were assigned to a BLS call due to no BLS units in the area, a fall where the patient struck his head/neck area on the curb of the sidewalk and complaining of head, neck and back pain. My medic partner was evaluating and I pulled out the board and collar...he told me to put it away as it is not needed, so I asked him if he was sure that we shouldn't immobilize and he again told me to put the board away. Then he started an IV. While transporting, I called base and asked for a supervisor to respond to the hospital for a patient care issue incident report. Well, while the medic was being reamed by the doctor in the ED, I was writing up an incident report with my supervisor to CYA myself. The ED did find trauma to C5, but luckily no neuro deficit. So, yes, this is a situation that required BLS skills and the medic screwed up. However, he is higher medical authority so I followed his orders and just did what I had to to cover my arse.

I agree. The difference is that law enforcement has a strong lobby and a solid salary history. EMS does not. Again, I agree. The general public only knows what they see on TV. You very rarely see advanced skills being done by EMS providers on TV or in the movies. In my region we have paid ALS fly cars with volunteer services providing BLS ambulances. I would say 90+% of our ALS criteria calls get ALS either on site or intercept and they are dispatched simultaneously with the BLS rig if the call info meets criteria. We also have access to ALS helicopter services, if necessary. So, the quality of care and response times are generally good and there is very little legal risk due to not providing necessary services. I consider ALS intercept capability a minimum requirement for rural areas.

I agree that IFTs are important. But, instead of splitting it completely from EMS, I think the ideal service is one that has a combination of IFT units and 911 units. Allow the crews to switch between the two to prevent burnout. Possibly consider the IFT unit a "Psychological Light Duty" job. Another idea, use the IFT units for new staff training and evaluation, then let them do some nursing home "emergencies", where the patient is coming from a stable environment before putting them on the 911 units. When I worked for a private ambulance, almost 70% of the IFTs were paid, so this was a solid revenue stream for the company.

Yes, they are, what happens if there are high CO levels in the house and you force entry to get to that patient laying on the floor...now we have 2 patients.

I beg to differ with you. Most of the volunteers that I know are involved in multiple community services. Personally, I serve on the board fo Directors of our Local Development Corp. I know other EMS/FD volunteers that volunteer to serve meals to the elderly, volunteer their time to repair community buildings, volunteer to help run the local community festivals, volunteer to staff local historical societies, etc. I would say that between 30% and 50% of the volunteer EMS providers I know are involved in other volunteer community based activities. Many people that have the "volunteer" spirit will volunteer where they think they will do the most good and can put their skills or talents to best use. On the topic of switching to a paid service, some of the comments that have been made here has gotten me thinking about the possibilities in my region and potential outcomes. Now that i have given it some more serious thought, one question keeps coming to mind... Why should I, or any other EMS provider, in a volunteer service spend time trying to convert to a paid service when the going salary is just above minimum wage? Yes, I know your argument about the volunteers causing the salaries to be lower, but I don't buy that it is the biggest problem facing EMS. Look at the NEMSA/AMR thread about Portland's attempt to get salary on par with other regions. If the EMS unions cannot support EMS provider attempts to get some parity on salary and other EMS providers do not support the effort (as exemplified by some of the comments in that thread), what will converting rural volunteer services to paid do for salaries? As far as I can tell, there are no volunteer EMS services in the Portland area, in fact, the AMR contract seems to cover EMS for several counties! So, the "volunteer effect" should be minimal there. And, the 3 cities mentioned are similar in size, so the cost of living should not be great enough to justify a 5k or 15k difference in base salary. Getting back to my local area, the salaries in EMS in the two closest cities start at $8 per hour, regardless of experience (and they are union!). I do not consider that a living wage and cannot, in good conscience, put anybody in the position of having to accept such a low salary that it would essentially be poverty level and that I, personally, would not accept. Keep in mind that the current poverty level according to HHS for a family of 3 is $17,170 (http://aspe.hhs.gov/poverty/07poverty.shtml), so working a 40 hour workweek at $8/hr (about $16, 885/yr) is under that threshold. I also realize that local government officials will press for salary parity with the nearby cities. If paid EMS is destined to become a job that can be turned into a career that everybody could live on, then salary increases must be seen. If you want to help convert volunteer services to paid, the paid providers must prove they are willing to step up to the plate and ask for more money. Knowing politicians, rural departments will most likely be mandated to base their salaries on comparisons with the nearest cities with paid services, then go a bit lower that that. I know it is a Catch-22, but look at it from a volunteer service point of view. Why should we go through the process of fighting politicians, educating the public, then go through the pain of creating/restructuring the department and getting a new CON (which in NYS can be a 2+ year process), when in the end, we will most likely be forced to lowball the salary and likely get lesser qualified candidates? If there was a snowball's chance in hell of getting base salaries for EMT-Bs close to the 30K per year mark, then I can see the effort being worth it. Several of you have made your point over and over again about not liking volunteer services. You (especially Dust) have made me think long and hard about this and even think about what I may be able to do from my little rural area. Please stop throwing the volly thing into so many threads, these anti-volly and anti-BLS posts distract a lot from the other posts and threads that discuss other issues. Overall, it gives this site a negative feel, which is a shame because there are so many good topics that have been discussed.

If it's a person with a known or reported medical condition, we will be dispatched simultaneous with PD and if there's no reported medical condition, PD responds first and we get called for a standby. For medic alert calls, our dispatch has a record of which neighbor or relative has a set of keys, if necessary.

I don't know anything about set EMTs, but I used to work for a company that provided event coverage for conceerts, sporting events, etc. In my state, there are regulations that cover event EMS requirements based on expected attendance. In all cases I dealt with, a staffed ambulance was needed on standby and as the number of people increased, the staffing and equipment requirements increased. I assume other states would have similar regulations on public gatherings. In addition, many smaller venues that skirted under the state public gathering laws still hired a BLS ambulance to standby at their events, just to shift medical liability to an EMS agency and potentially reduced their insurance costs. As for working independent from an EMS agency, I would ask the company or night club if they meet your state's EMS event staffing laws and if they have medical malpractice insurance that would cover you as an employee. I don't have a problem with using your own equipment, but make sure everything is up to snuff, because that has the potential to make you liable for any equipment issues instead of the employer.

How about flight nurse? I'm not sure if this is everywhere, but the 2 local medevac helicopter services in our area are staffed with a pilot, Paramedic and a Flight Nurse.

In my current department, the fire side is mostly male, but the EMS side is about 60/40. In previous EMS agencies I have been with, there was also a decent female representation.

To stay on topic, I was also a bit disappointed at the strength of the anti-vollie response I received in a couple of other topics...but I decided to lurk a bit more and read the opinions of the other posters to get a better understanding of the reason for their opinion. I also currently volunteer as an EMT-B in a rural area and I worked in a paid system before changing careers. I enjoy working int he EMS system, regardless of paid or volunteer. When I decided to change careers, it was a tough decision. At the time that I was trying to decide on whether to stay in EMS, I was also looking at my future and moving to a rural area, where there are less paid EMS opportunities. I also looked at salaries and the expense of getting certified at a higher level. If salaries in EMS were dramatically better and I saw more chance of advancement, then I probably would have remained in a paid EMS service and upgraded to EMT-P. That being said, when I moved to upstate NY, I discovered that the paid services (even in the small cities within driving distance) have extremely low-balled their salaries. It is a shame that I was getting paid better as a fresh EMT-B (15 years ago) in a private ambulance in NYC than paramedics with a boatload of experience are getting paid in my region now. What is even worse is that in my current field of employment, I took a 20% pay cut when I changed employers. Talking to people in other industries, that seems to be the average salary difference between my region of upstate NY and NYC, so I would have expected EMS to have a similar salary difference, not have a salary of almost 50% less. Now, I also see how rural services work and the budgetary constraints involved, so I see the need for volunteer services in rural areas. Can it be done as a paid service...possibly. I am open to the idea, but I do not think it will work everywhere. I also do not subscribe to the theory that volunteers are the main reason why EMS salaries are low. Volunteer services may have an affect on salaries at the BLS level, but from what I have seen in NYS, there are very few volunteer services that provide ALS, and many that do are not 24/7 ALS. So, why are paramedic salaries so low. I personally think the primary reason is greedy corporations and a lack of a unified EMS voice. What I'm basically trying to say is that I have seen both sides of the argument and I don't think it is as black and white as some people have posted previously. Also, I am not here to be argumentative, rather, I want to see EMS as a whole improve. In my opinion, all EMS providers, paid or volunteer, should be trying to improve themselves and their quality of care. In that vein, I will not hesitate to chime in when I think I have something of merit to add and I will continue to visit because of the wealth of posts and ideas throughout the forum.

What really needs to be done is implementation of Treat and Release protocols or alternative destinations. For a patient that we know doesn't need to be transported (stubbed toe type calls), let the EMS provider treat the patient and get a signature release. Another option for non-life threatening calls could be transport or referral to a doctor's office or a walk-in clinic. Many of the calls we see do not need a full blown ER and this would free up ER resources and has the potential of reducing transport and ER wait times, thereby improving EMS unit availability. I know there was some talk a few years ago to allow transport of stable patients to 24-hour clinics, but I have not heard anything more in a long time. I don't think it went anywhere in this region. Of course, with our litigous society, these options will be frowned upon. In fact, our Regional Medical Council director has flat out told us that he does not like RMAs and wants agencies in our region to reduce the number of RMAs we allow.

This is a bad idea. As the articles states "Chadron City Attorney Adam Edmond says false reporting is covered by state law". If it is obvious that a person called 911 frivolously, then they should be brought up on charges under exisiting state law. There is no justification, regardless of whether a locality uses a volunteer or paid service, to pass any laws that may make a civilian not call 911. I would prefer getting up at 3 AM to a non-critical call because someone erred on the side of caution rather than hearing in the news about someone dying at home because they were afraid to call 911. If those volunteers are complaining, then maybe they should look at themselves and decide whether they, as individuals, should be in EMS (or any other emergency service) at all.

Volunteerism may affect salaries in some areas. However, in many rural settings, there is no other option. When you have a community that averages 300 calls (or less) per year, it is hard to justify paying several full time salaries to cover it and when coverage areas are measured in 40+ square miles, response times from a paid service, not based in the community, would be just as high or higher than the current volunteer service. The ultimate side effect of going fully paid would be a drastic increase in taxes in rural areas. As far as other effects on salaries, from what I have seen, the biggest downward pressure on salaries is lack of competition. When I lived in NYC, the paid services had to compete for qualified EMTs and medics. This helped to increase their salaries. The hospital based services seemed to offer a higher salary in hopes of getting better qualified and experienced staff. Where I live now, in upstate rural NY, the ALS fly car provider in my county starts out at $10/hr for paramedics. Their nearest paid ALS EMS competitor is over 50 miles away, so they don't need to increase their salaries. Not to mention, there are very few ALS spots, with more ALS providers than available slots. Going in the other direction, headed towards Lake Ontario, where there is a higher population and an increase in the number of paid services, salaries do increase.

That's an interesting point. Here's a study that compares before and after accident rates at red-light controlled intersections: http://www.tfhrc.gov/safety/pubs/05049/ The study shows overall expenses due to crashes to be decreased. It also shows that, of the sites studied, there were 379 fewer right angle collisions, but 375 more rear-end collisions. This study also summarized some potential recommendations on placement of red light cameras. The point I was trying to make is that when responding L+S and approaching an intersection with a red-light camera, emergency vehicle drivers now have to worry about another factor that increases the unpredictability of other drivers.

In my region of rural upstate NY, we have volunteer BLS units with ALS fly cars. My department is on the border of 2 counties and the counties have a mutual aid agreement in place, so we usually get an ALS fly car out of the next county. That county provides 2 ALS fly cars and they are always running. We almost never get ALS from our own county (provided by a private service), but our county is huge, about the size of Rhode Island and they only provide 2 ALS fly cars outside of the 2 "cities" in the county that have their own paid services. One of the problems is the regressive regional council for our county. They recently mandated ALS response to more BLS calls. This is increasing ALS usage, but decreasing their availability for true ALS calls. I would say better than 90% of the time the BLS volunteer squads get on scene either before or with the ALS fly car. Several of the local volunteer departments also have a unique mutual aid system in place, where if one dept has a driver and a neighboring dept has an EMT, they can meet up and staff the driver's rig. It doesn't happen often, but it does help get staffing during the daytime. My dept also has the advantage of having the 2nd largest employer in the county within our town limits. Their corporate policy allows responders to leave work for Fire or EMS calls. In a rural area, I think it is very important for companies to support the volunteers in this fashion.

LOL Considering that I've been making money at my 2nd hobby for about 10 years, it's no longer just a hobby, it's a career. The only thing I see doing over the near future is working on expanding my business and hopefully making enough money to allow me to leave my full time job.

I think Red Light cameras are more dangerous than any other municipal revenue generator (ahem, I mean "traffic control tool"). In my experience, all of the locals learn where the cameras are and many drivers slam on their brakes when the light turns yellow to avoid a ticket, sometimes causing an accident. Because of this, I think all emergency vehicles need to be extra cautious when approaching an intersection with a red light camera, even when you have the green light.

I got into EMS with my college's Rescue Squad. I graduated with a BS in Meteorology and a license to work on merchant ships, but I decided to go into EMS full time after college. I did that for 3 and a half years, until I realized that salaries were not that good. So, I fell back on my hobby, computers. Got Microsoft certifications and landed a full time job with a dot com company that gave me a 40 hour work week with double the salary that I was making doing 50+ hours in EMS. I am now working as a software support engineer at night, while building up my home business providing computer services to small businesses in my area. I am still very active in EMS though. I started out volunteeing in college and have never stop working for volunteer EMS. I now ride as an EMT with my local volunteer Fire Dept and currently serve as the EMS Lt.

I would never slap a patient, regardless of whether it was a "tap" or not. The only ways I check for responsiveness are to tap on shoulders (as taught in the old style CPR) and sternal rub/nail bed pressure. IMO, slapping a patient in the face like that is an open invitiaion for at least a civilian complaint. If not the patient, then by a bystander.