While Rural communities are at the tip of this spear – many of these same issues are happening in urban and suburban areas as well.

NAEMT is working on a project to try and create a Critical Access Ambulance Provider designation that would function with the same eligibility and reimbursement model and Critical Access Hospitals.

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Rural emergency hospital model exposes ambulance service gaps

ALEX KACIK

February 22, 2024

https://www.modernhealthcare.com/providers/cms-rural-emergency-hospital-model-ambulance-services-anson-general

Anson General Hospital needed to transfer a pediatric patient to a specialist at Cook Children’s Medical Center in Fort Worth, Texas, but the only ambulance in Anson wasn’t available.

If it had made the 340-mile round trip during a night of heavy rain on Feb. 10, no ambulance would have been available to handle 911 calls. As a result, Anson General had to keep the patient overnight in the emergency department.

The next morning, the ambulance transported the child 25 miles to the airport in Abilene, where Cook Children’s had dispatched a plane for him.

“We are the only hospital left in Jones County, since the other two hospitals closed," said Anna Doan, chief nursing officer at Anson General. “Those communities bring us patients on a daily basis. When a patient has more acute needs and needs to be transferred to a tertiary facility, the problem arises: How are we going to get them there?”

It doesn't take much to upend emergency transportation services in rural communities, which have been plagued for years by limited ambulance networks.

Many hospitals used to operate ambulance services, but that dynamic has shifted as rural hospitals finances have deteriorated. Rural hospitals often rely on one or two ambulances, oftentimes operated by volunteers, to transfer patients and handle 911 calls. A new hospital designation—rural emergency hospital—threatens to derail the fragile system.

Twenty hospitals have converted to rural emergency hospitals about a year since the federal program was implemented. Hospitals forgo their inpatient beds, among other trade-offs, in exchange for a 5% increase in Medicare outpatient reimbursement and an average facility fee payment of more than $3.2 million a year.

More hospitals are expected to convert, potentially requiring more ambulance transfers of patients to hospitals with inpatient beds. Since Anson General converted in March, on average it has transferred roughly 20 patients a month, versus 15 previously.

“The rural emergency hospital legislation was notably missing considerations about ambulance services,” said Gary Wingrove, president of the Paramedic Foundation, a nonprofit research and advocacy group and a member of a federal advisory committee on ground ambulance and patient billing. “That is a big unintended consequence.”

Ambulance services are typically fueled by a tenuous stream of subsidies from local jurisdictions and providers. When funding falls through, communities can lose emergency transportation services, potentially overloading area hospitals and causing delays in patient care. The situation has prompted pushes from local, state and federal policymakers to overhaul the reimbursement model.

According to the latest Medicare cost report data, only 18% of rural hospitals bill Medicare for ambulance services, meaning that communities largely lean on volunteer-run and third-party contractors, according to a data analysis by consultancy the Chartis Center for Rural Health.

Jones County, where Anson General is located, is reviewing a contract expiring in March for the city’s sole ambulance.

“Not having a 911 service would be detrimental to the community. People could lose their lives,” Doan said. “It could have a big impact on patient care, changing the patient flow in ERs and how long transfers take.”

Other rural communities could face similar predicaments since many towns are grappling with declining populations, worsening socioeconomic conditions and Medicare reimbursement cuts, particularly as more people age into the program, Anson General Interim CEO Ted Matthews said. 

It costs roughly $1 million a year to fund an ambulance service, research shows. Roughly 4.5 million people live in an ambulance desert, defined as an area where a dispatch station is at least 25 miles away, according to a report published in May by the Maine Rural Health Research Center, which is associated with University of Southern Maine.

The cost is prohibitive for many hospitals, cities and counties. In those areas, ambulance services are operated by volunteers and owned by third-party contractors.

“We’re expecting the people who are going to decide whether you live or die to be volunteers,” Wingrove said. “That just doesn’t work.”

Only one of the ambulances covering Friend, Nebraska, operates 24/7. The other two volunteer-run ambulances have limited hours and select routes.

In July, Warren Memorial in Friend had a complex bariatric patient who needed to be transferred to a larger hospital in Lincoln, Nebraska. Administrators called 12 different transport companies and none would take him. Their vehicles lacked the specialized equipment to shuttle an obese patient.

“He ended up staying here all night when he could’ve gotten better treatment in Lincoln,” said Jared Chaffin, chief financial officer and interim co-CEO of Friend Community Healthcare System, which operates Warren Memorial. While care was delayed, the patient ended up OK, Chaffin added.

Administrators at Warren Memorial, which converted to a rural emergency hospital this month, are worried about the impact to the area's transportation network since the hospital no longer has inpatient capacity.

Not everyone expects the rural emergency hospital program to strain transportation services. Most of the hospitals that convert were not admitting many emergent patients, said Eric Shell, board chair with the consultancy Stroudwater Associates who specializes in rural healthcare. Even if they did, most of the hospitals would be able to treat those patients under observation, as permitted by the rural emergency hospital program, as long as the average annual length of stay for observation patients remains below 24 hours, he said.

That's the case at Santa Rosa, New Mexico-based Guadalupe County Hospital, which converted in September. The hospital hasn’t seen an increase in transfers since it already had relatively few admissions, and those who had been admitted were treated as observation patients, Administrator Christina Campos said.

Still, regardless of the impact of the rural emergency hospital program, a more sustainable funding model is needed for emergency transportation services, experts said.

Some industry observers are pushing for cost-based reimbursement for ambulance operators, similar to the critical access hospital model. As part of the No Surprises Act, legislation implemented in 2022 intended to shield patients from surprise bills, the federal government appointed an advisory committee on ground ambulance and patient billing. Ground ambulances are exempted from the law.

That committee will soon publish a report that supports a cost-based payment model for ambulance services, said the Paramedic Foundation’s Wingrove, a member of the committee.

“It is a misnomer to think you can pay for an ambulance service through reimbursement alone. The math simply isn’t there,” said Andy Gienapp, deputy executive director of the National Association of Emergency Medical Services Officials.

“This problem has been a festering wound for decades now.”