News & Updates

Another example of the critical role EMS plays in rural communities!

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How Rural Communities Are Using EMS to Help Solve the Opioid Crisis

June 27, 2025

https://www.phi.org/press/calhealth-report-how-rural-communities-are-using-ems-to-help-solve-the-opioid-crisis/

“California is one of just five states in which the rate of death from drug overdoses is higher in rural areas than urban ones, according to data from the Centers for Disease Control and Prevention. The latest data from the California Department of Public Health shows that statewide, more than 7,800 people died from opioid overdoses in 2023, the most recent year statistics are available. While Los Angeles County recorded the highest total number of opioid-related overdose deaths in 2023 at 7,847, when adjusted for population size, Alpine and Sierra counties had the highest rates, though this data is less stable given the counties’ small total population size.

Because rural EMS units often rely on volunteer crews and face geographic barriers that force them to cover large distances in more varied terrain, response times are typically slower, according to the federal Centers for Disease Control and Prevention. In California, urban EMS providers also tend to receive more funding, resulting in a higher quality of care, according to the CDC. But across the state, emergency responders in rural regions are finding solutions tailored to their communities. Driven by a desire to help patients find long-term help for drug use, emergency providers are partnering with local organizations to connect patients with mental health care and treatment programs, as well as equip communities to distribute overdose-reversal medication.

Long-term treatment, from the ambulance

Sometimes, the long-term care that patients need includes mental health treatment; other times, it’s more directly related to substance use. For patients with opioid use disorder, medications, such as methadone and buprenorphine, can be an important tool. These medications, opiates themselves, mimic the effects of opioids to help prevent withdrawal symptoms without giving the patient a sense of “high.” Usually distributed under the care of a physician in a clinic or hospital, some EMS units are finding ways to start that treatment before patients even reach the hospital.

Following an overdose, many patients refuse to be transferred to a hospital, or they leave the hospital before a long-term care plan can be established, according to EMS Bridge, a program within California Bridge to Treatment, which works to use EMS services to advance community health. Either way, surviving an overdose can trigger painful withdrawal symptoms that have historically been difficult for medics to treat. But in the last few years, some EMS units across the state and country have experimented with providing medications that help withdrawal symptoms in the ambulance before patients even reach the hospital.

In 2019, clinicians at Cooper University Health in Camden, New Jersey, began a groundbreaking experiment. They trained paramedics to begin treatment with buprenorphine in the ambulance, a practice that had historically been limited to physicians in a clinic. It was a massive success: patients who were offered methadone or buprenorphine pre-hospital were six times as likely to use it, vastly increasing their chances of long-term treatment. Clinicians in California began wondering if they could bring the same success to their communities.

Beginning with a small pilot project in Contra Costa County in 2020, EMS Bridge, a program of the Public Health Institute’s Bridge Center, began a program to train EMS professionals to administer buprenorphine through funding from CARESTAR. “If you have an overdose and survive it, you have a 10 percent change of dying within a year,” said Dr. Gene Hern, medical director for EMS Bridge and associate clinical professor of emergency medicine at UCSF. But treatment with buprenorphine can lower that mortality rate by 70 percent—a success that Hern said is unparalleled within emergency medicine.

According to the Department of Health Care Services, 1,300 paramedics across 13 California counties have been trained to administer buprenorphine in the ambulance, and with new funding, Stanislaus County will be next. Hern said that adoption in rural California can be limited because patients will need a reliable, accessible place to continue getting medication once transferred. But he sees some strengths in rural areas as well. Longer transport times can mean that medics have more time to connect with their patients, establishing a trusting relationship in which a patient may be more open to starting buprenorphine.

Being able to help patients find long-term care helps medics, too, said Vanessa Lara, EMS Bridge Program Manager. While quantitative data is difficult to collect, she said their surveys indicate that being able to watch a patient transform before their eyes helps medics feel more satisfaction in their work, as does knowing that they helped put them on a path toward long-term healing.”

Click on the link below to read the full article.

How Rural Communities Are Using EMS to Help Solve the Opioid Crisis.pdf

All the way back in 1907, the American Medical Association published this editorial in their journal.

Key Quotes:

"One feature of the accounts of ambulance accidents is that in the majority of cases the ailment of the sufferer who is being taken to the hospital is not such as demands speed to save either life or suffering."

"The rushing across avenues crowded with traffic should never be permitted except under the most urgent conditions, and those absolutely known beforehand and not merely presumed on general principles."

"… a reduction in the number of accidents to ambulances must come rather from stringent enforcement of certain precautionary regulations rather than from renewed efforts to have the right of way…"

"It is needless to remark that such stringent regulations should be enforced with regard to ambulance service as will lessen the number of accidents."

Highlights - JAMA Editorial 1907.pdf

Mass. EMS bills a first step to speed up ambulances and save lives

By Angela Mathew

June 25, 2025

https://www.bostonglobe.com/2025/06/25/metro/mass-ems-bills-first-step-speed-up-ambulances-save-lives/

“The EMS system in our state is broken,” Feeley testified Wednesday at a hearing on the Legislature’s Joint Committee on Public Health. “Unfortunately, I witnessed its failures firsthand.”

An EMT at the hearing teared up listening to Feeley’s testimony during the hearing that addressed several pending bills related to local public health and emergency services.

Some municipalities, such as Boston, are large enough that they operate their own EMS services.

However, around 80 percent of the state’s licensed ambulances are operated by private companies that bid for the right to serve each town’s population, the Globe previously reported.

Those private companies have not been able to hire and maintain adequate staff, which has led to ambulance delays, according to the Globe’s coverage.

The state also doesn’t have a centralized system to coordinate ambulances and send them to another town in case of a shortage.

A slate of bills intends to address the delays, most notably by designating EMS as an essential service in the state, and would create a fund to pay for its operation, according to the bill posted online.

Other legislation would set up a committee to oversee EMS and to pilot a program for EMS workers to

treat patients “in place,” instead of driving them to the hospital, when appropriate.

Other bills discussed at the hearing propose requiring that all 911 dispatchers in the state be trained to instruct people how to do CPR over the phone and creating a database that lists defibrillators across the state.

The bill to make EMS an essential service proposes creating a fund to support EMS agencies and pay for things such as training, equipment, vehicles, and personnel salaries.

Representative Leigh Davis, a Democrat of Great Barrington, who sponsored the bill said that for too long, EMS has been underfunded and is not always covered by patients’ insurance.

“In 1973, the federal EMS Act left it up to the states to fund EMS, never recognizing it as an essential service,” Davis said. “Unlike police and fire, there’s no guaranteed funding, just donations, inconsistent local budgets, and low insurance reimbursement rates.”

Mike Woronka, chief executive officer of Action Ambulance, a private company, said that as baby boomers retire, his company has found it difficult to fill EMS positions, making existing employees’ jobs harder.

“We are beyond the crisis stage, it is affecting our staff, and it’s affecting the residents of this Commonwealth,” Woronka said.

Tina Dixson, an advanced EMT who has worked for 27 years in the Central Massachusetts towns of Hubbardston and Holden said she supports the bill to create a special commission on EMS.

“If you pictured an EMT in a neatly pressed uniform, working … with the calmness and precision of a NASCAR pit crew, but with the bedside manner of Mr. Rogers, that isn’t always the case,” Dixson said, “We need a lot of assistance with some of the things in these bills.”

Dixson also spoke in favor of bills creating a database for defibrillators so that people can locate one close to them in cases of emergency.

Matt Zavadsky, a past president of the National Association of EMTs, said he supports the designation of EMS as an essential service, but noted the bill does not identify a funding source.

Zavadsky said that it would be better for the state to designate EMS an essential service, and require localities to fund operations based on their own needs.

“Should the state set a standard that in rural areas in the Berkshires the response time should be 12 minutes?” Zavadsky said. “And do they pick the provider they’re going to contract with to provide that service? … It [should be] up to the local community to decide that.”

For the bill proposing a pilot program for EMS workers to treat people “in place,” Zavadsky said there needs to be an emphasis requiring insurers pay for treatment in place as opposed to only covering transportation to a hospital.

“Treatment in place is already proven, there’s enough data out there to show that it’s safe and it saves money,” he said. “Payment models drive clinical practice, so we need the bill to require that insurers pay for treatment in place.

Kansas City, MO was once served by a Public Utility Model EMS system, the Metropolitan Ambulance Services Trust (MAST) until it was transitioned to the Kansas City Fire Department in 2010. At the time, some local leaders were concerned that the quality of care would suffer.

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Secret KCFD audit found ‘alarming’ lack of compliance with heart attack protocols

By Mike Hendricks Updated

June 25, 2025 

https://www.kansascity.com/news/local/article309294265.html

The Kansas City Fire Department’s paramedics and emergency medical technicians failed to follow the approved protocols for treating chest pain 87% of the time they were called to an emergency, according to an internal audit obtained by The Star through an open records request.

That poor performance put Kansas City residents experiencing heart attack symptoms at greater risk of not receiving the treatment they needed in time to avoid poorer health outcomes or even death, the audit said. And according to a recent lawsuit that first revealed the existence of the audit, the failure of Kansas City’s emergency responders to follow those protocols presented “a very specific danger to public health and safety.”

To put it simply: Kansas Citians could be dying from heart attacks unnecessarily because firefighters are frequently making errors or skipping steps in their emergency response.

Deputy Chief Laura Ragusa, the department’s chief medical officer, initiated the audit and analyzed the data after receiving field reports from department supervisors who were concerned about the level of care patients were receiving from the department’s emergency responders.

She presented her findings to Fire Chief Ross Grundyson on March 13, along with suggestions on how to improve performance through more rigorous training and testing, according to her audit report and the whistleblower and employment discrimination lawsuit she filed against the city in Jackson County Circuit Court.

Ragusa’s report placed blame for the poor response on what she described as the department’s lack of emphasis on its emergency medical treatment services, despite the fact that medical calls account for 76% of the department’s emergency calls, while fire suppression calls make up only 16%.

“Rank and file employees are begging for training, especially hands-on training,” the report said and set out specific benchmarks for increasing protocol compliance.

But rather than act on her findings, Grundyson suppressed the report, Ragusa claims. He ordered her to “not share the data with anyone outside the department,” the lawsuit says. The audit summary also notes that.

Shared data with city officials

Ragusa had planned to share her findings with the city’s Emergency Medical Services Coordinating Committee the following week on March 19. That committee includes people from within and outside the department. Members include the fire chief, the city’s health director, an emergency room doctor not employed by the city, as well as two paramedics, two emergency medical technicians (EMTs) and the city manager, who chairs the committee.

But Ragusa did not share the data with the committee, according to minutes of that meeting on the city clerk’s website.

She did, however, defy Grundyson’s order that same day when, according to court documents, she and the city’s medical director, Dr. Erica Carney, met privately with Interim City Manager Kimiko Black Gilmore and Mayor Pro-tem Ryana Parks-Shaw.

Ragusa provided Gilmore and Parks-Shaw with packets of information “outlining the areas of concern from the audit and their recommended plans to address the issue.”

Among those plans was Ragusa’s suggestion that the department conduct another audit to measure the competency of the department’s paramedics and EMTs. Any inadequacies found would then be addressed with additional training and regular tests to measure skills and compliance with the department’s treatment protocols.

Ragusa and Carney declined The Star’s request for comment. Gilmore and Parks-Shaw did not respond when asked via email for their reactions to the audit’s findings.

When asked to comment on the audit’s findings and the allegations within Ragusa’s lawsuit, the fire department issued only a brief, written statement:

“Due to the ongoing litigation, Chief Grundyson is unable to comment on the unvalidated internal report but does state that he has the upmost confidence in the skills and abilities of the members of KCFD. He is certain they will continue to provide the high-quality care and service that they always have.”

Audit’s finding ‘alarming’

Ragusa’s lawsuit called the audit’s findings “alarming.”

Her statistical analysis of emergency response reports found that KCFD personnel followed all the protocols for treating chest pain just 13.2% of the time during the two-month study period, and only 8.3% of the time when treating acute respiratory distress. Patients with that condition experience shortness of breath and low blood oxygen levels.

Overall compliance with treatment protocols in assessing and treating patients for all conditions was 17%.

The protocols are set out in a 186-page rulebook last updated by the department medical director in September 2024 and based on national standards. The chest pain protocols are on page 72 and tell emergency responders what to do — from obtaining vital signs, to applying a cardiac monitor, to whether they should administer nitroglycerin to a heart attack patient.

In the case of a patient who has taken medications for erectile dysfunction in the past 36 hours, the answer in that case would be no.

The audit does not identify which protocols were not being followed. It could be as simple – and often crucial – as failing to provide a patient with low-dose aspirin to help prevent blood clots. A 2009 study in the medical journal Prehospital Emergency Care found that EMS personnel often failed to have patients chew an aspirin tablet when that might have helped more than other treatment.

But Ragusa’s audit report does not state what lapses were most frequent. She recommended following up with quarterly audits that might provide more detail and increase protocol compliance to 50% by the end of 2025.

While the results reflected problems with the department’s medical response overall, Ragusa concluded that the people most at risk are those in lower socio-economic groups, which have the highest number of calls for service. People living in those ZIP codes are also less likely to have someone in their households with CPR training who can provide aid while waiting for an ambulance to arrive.

“Cardiac arrest survivability is drastically increased with bystander CPR,” the report said.

The results were based on analyzing a sample of 10% of the 13,000-plus emergency medical call responses during those two months, and 100% of the chest pain and acute respiratory distress calls.

A medical professional familiar with the study’s findings said the results were concerning.

“I am scared for our patients,” said that person, who spoke to The Star on the condition of anonymity, fearing retaliation from city officials for speaking out.

Alleged acts of retaliation

Ragusa’s allegations about the audit and the fire chief’s response to it are but one section of a multi-part lawsuit that alleges a pattern of workplace discrimination toward her as the highest-ranking woman within the department’s uniformed personnel.

The Star previously reported on one aspect of her case concerning the city’s prolonged search for someone to serve as the permanent chief of the fire department. Grundyson has filled the position in an interim capacity for two and a half years.

The city launched a nationwide search in early 2023 for her replacement after former Chief Donna Lake retired. But it then suspended the search that December, with the explanation that Grundyson needed to stay on until a new labor contract was negotiated with International Association of Fire Fighters Local 42, the union that represents the majority of the department’s firefighters.

The search resumed last October, after the contract was signed, and the deadline for applications was two weeks ago, on June 10.

Ragusa alleged in her suit that the city discriminated against her, as well as other female and minority candidates, by refusing to interview them for the job back when it was first advertised.

Ragusa said that she is better qualified to lead the department than Grundyson, who like all but two fire chiefs in the history of the department is a white man.

According to her lawsuit, Grundyson has expressed interest in remaining chief until 2027, and City Manager Mario Vasquez has not ruled that out.

Ragusa filed a shorter, first draft of her lawsuit in February. It alleged that Grundyson had discriminated against her after she informed him of what she believed were illegal and unethical practices related to department contracts, medical billing and reporting requirements for federal reimbursements.

She said Grundyson retaliated against her by minimizing her contributions to the emergency response during the fatal shooting at the 2024 Super Bowl victory rally, while praising the actions of her male colleagues. He also removed her from key assignments, such as a committee making security arrangements for the World Cup soccer tournament, she said.

“The current Fire Chief has engaged in an ongoing, continuing pattern of discrimination and harassment of Plaintiff based upon her sex that has resulted in a hostile work environment,” the lawsuit said.

An excellent summary of the issues related to CMS’ Emergency Triage, Treatment and Transport (ET3) model in Health Affairs on June 23, 2025.
 
For each patient enrolled in the ET3 mode, the average Net Savings to Medicare (NSM) is shown below. Treatment in Place (TIP) models are patient-centric models that have the potential to save hundreds of millions of dollars to the Medicare program.

A summary of the economic case for EMS TIP programs can be found here.
 
We encourage EMS and stakeholders to support current legislation that changes Medicare’s EMS payment model to reimburse for TIP and MIH.
 
H.R. 2538 - Comprehensive Alternative Response for Emergencies (CARE) Act of 2025 (TIP Bill)
H.R. 4011 – Community Paramedicine Act of 2025

Learning From The Failure Of A CMS Emergency Medical Services Model
Erik Blutinger, Alexander J. Ulintz, Kevin Chason, Nicholas Gavin
June 23, 2025
 
https://www.healthaffairs.org/content/forefront/learning-failure-cms-emergency-medical-services-model
 
Barely one year after the eruption of the global COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) launched an exciting initiative for Medicare fee-for-service beneficiaries. The Emergency Triage, Treat, and Transport (ET3) Model afforded one of three outcomes for every patient encounter: ambulance transport to a covered destination (that is, a hospital emergency department), ambulance transport to an alternative destination (for example, urgent care), or treatment in place (emergency medical service [EMS] on scene with telehealth physician consult). The program—a voluntary, five-year payment model covering prehospital services beyond emergency stabilization and transportation—sought to answer a critical question: Is there a better way to deliver acute, unscheduled care to older adults in the community without defaulting to expensive, intensive care settings?
 
However, CMS abruptly announced the death of ET3 in 2023. Another planned aspect of the model, which would have provided up to $34 million for local emergency communications centers to establish or expand medical triage lines, was canceled prior to implementation after CMS received fewer than 30 applications.
 
The recent publication of CMS’s final report provided insights into the limited participation and other challenges that prevented the model from flourishing, but the current landscape leaves EMS agencies, emergency departments, and other key stakeholders stuck in a current of costly prehospital acute care services while trying to paddle upstream toward value-based care. This article examines the forces that led to an early termination of ET3 but laid the groundwork and set the trajectory for value-based care and EMS-led innovation.
 
What ET3 Was Trying To Solve
Over the past two decades, the EMS community has realized that person-centered, value-based care could look very different than the traditional model of transporting all patients to an emergency department. “Community paramedicine” programs, which emerged in the 1990s, filled critical health care gaps in rural America. This concept gained momentum in the 2010s after passage of the Affordable Care Act spurred an interest in value-based models. Several state Medicaid programs reimburse for community paramedic services, and some EMS systems have launched programs funded by local taxpayers or agreements with providers and payers. In 2019, EMS Agenda 2050 envisioned systems of care, integrated with EMS, that allowed the right level of care in the right setting to be delivered to the patient, with reimbursement for the value of the service provided. This broader concept—extending EMS beyond its transport function and expanding its patient navigation function in coordination with health systems and community services—is increasingly known as “mobile integrated health” (MIH). The dream of MIH, however, was often limited to grant-funded pilot programs, including some supported by the Center for Medicare and Medicaid Innovation.
 
Historically, Medicare primarily has paid emergency ground ambulance services for transporting individuals to expensive facilities such as traditional hospitals, critical access hospitals, dialysis centers, and skilled nursing facilities. As a result, when calling 9-1-1, beneficiaries typically get taken to a hospital emergency department rather than a destination or outcome that, in some cases, may align better with their medical needs and personal preferences for receiving care outside of the emergency department.
 
The misalignment between the services that EMS provides and reimbursement solely for its transportation function leads to inefficiency and potentially unnecessary Medicare spending. The downstream consequences of this model are significant: high costs of care in intensive settings, emergency department overcrowding, longer EMS wait times during an emergency. Moreover, EMS agencies, already running on thin margins, are often not reimbursed for the emergency response, acute care, medications, and supplies used if a patient does not want—or does not need—transportation to a reimbursable destination.
 
Recognizing these inefficiencies, EMS agencies have long advocated for alternative care models, leading to experimental programs such as ET3.
 
ET3, Organization Design And Operational Dynamics
The prehospital community was excited to have a path toward sustainably offering patients a customized care path rather than defaulting to sometimes unnecessary transportation to an intensive and expensive care setting. In March 2021, CMS unveiled a list of 184 public and private ambulance providers and suppliers selected to participate. Enthusiasm grew as the groundwork was laid for a paradigm shift in prehospital medicine.
 
Overall, model participants were afforded generous flexibility for tailoring their own care pathways. New care protocols were built from an early stage. Communities stood up new structures for building novel interventions and new procedures even in places such as New York City, whose Fire Department of New York organized weekly meetings with major health systems to discuss recommended “best practices.”
 
New protocols and procedures also were greeted with overwhelming optimism by the EMS community and patients in parts of the country. Interest in out-of-hospital care is high especially when telehealth becomes a new option for patients to receive care in the comfort of their homes. With ET3’s goals of person-centered care, increased efficiency in the EMS system, and growing technological capabilities in the out-of-hospital environment, systems were willing to invest, build new protocols, and develop new policies for meeting consumer demand.
 
Several barriers, however, impeded overall progress and acceptance of ET3. The lack of cultural acceptance, high administrative costs, and challenging care coordination seemed to limit potential outcomes. Implementation challenges quickly became apparent, as participation rates lagged, and adoption—even among highly motivated participating agencies—was hindered. According to CMS, from January 1, 2021, to December 30, 2023, 147 EMS agencies participated in the model but only 72 (49 percent) submitted a claim for these services. The number of unique Medicare and Medicaid beneficiaries who received an ET3 intervention was 2,964, suggesting an average of 41 patients per provider. There were also many more treatment-in-place interventions (3,144) than transports to alternate destinations (253).
 
ET3 could have demonstrated significant cost savings by diverting preventable emergency department visits through treatment in place with telehealth or transport to alternative destinations such as urgent care. The program, however, was canceled early, partially attributable to delays in implementation and slow uptake of systemwide interventions.
 
 
Why ET3 Failed
Out-of-hospital care is popular yet often associated with costs and limited resources. The final report underscores the administrative, operational, and reimbursement complexity that EMS systems face when implementing innovative programs, even with federal and community support. Significant barriers prevented model participation in most local health care Marketplaces: Many health systems and departments rely upon fee-for-service, volume-driven care models versus programs with value-based care elements such as ET3 that was intended to reduce emergency department volume and inpatient admissions. Value-based care programs have faced their fair share of challenges in health care but still represent an aspirational goal in the United States, to blunt the long-term trajectory of ever-rising health care costs.
 
The post-public health emergency era has introduced changing policy, payment, and coding surrounding virtual health care visits. Major health stakeholders are struggling to predict future health trends especially now that COVID-19-era–related policies are no longer in effect. After COVID-19, many health systems have not experienced healthy operating margins, prompting executives to “think twice” about alternative care models that have yet to prove long-term financial sustainability.
Onward And Upward
 
So, what now?
Despite the premature closure of the ET3 pilot, the national appetite for value-based care beyond the four walls of a clinic or hospital continues to grow, as does innovation in MIH. Future efforts should: Balance local flexibility in program design with clear federal reimbursement structures that are feasible for small MIH programs to participate in; integrate MIH into existing value-based payment infrastructure, including broader insurance participation beyond Medicare; and support rigorous evaluation of similar MIH programs that continue to flourish across the country.
 
Data will require prioritization, too. The collection and comparison of systematic data is indispensable for meeting individualized community needs as it pertains to areas such as billing procedures, EMS payment model structuring, and cultural acceptance of new home-based technologies. Future partnerships with private payers may also help with the acquisition, accessibility, and overall processing of patient-level data. It is difficult to understand care delivery without data—a key pillar to any future program that aims to replicate parts of ET3.
 
There is no innovation and creativity without failure. ET3 failed due to problems with program implementation, resource allocation, financial incentives with ongoing focus on fee-for-service arrangements, and cultural acceptance within both EMS and its health care partners. But the program should be considered a landmark success for its ability to pioneer new ideas with good intentions in EMS. The model’s challenges have provided valuable lessons for policy makers and health care systems to reopen the door for sustainable, value-based EMS care for years to come.

While the headline is a little deceiving (every agency referenced in the report is a governmental agency), this lengthy news report is very well done.
 
Ambulance agencies resort to processes like these to collect owed fees from patients when insurers make surprise under-reimbursements for services in order to reduce public tax burden from communities. 
 
Scenarios like these are why the ambulance industry, being good patient advocates, continues to push for patient protection initiatives that require insurers to appropriately reimburse ambulance agencies.
 
The May 2025 PWW|AG Financial Index Report provides data on the under-reimbursement of ambulance services by commercial insurers.

Special thanks to John (JP) Peterson from MEDIC in Charlotte and Regina Godette-Crawford from EMS|MC for providing insight for this news report, and to Brian LaCroix from Cambridge Consulting Group for finding and sharing this report.

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Ambulance companies collect millions by seizing wages, state tax refunds
Some ambulance patients are surprised to find their wages or tax refunds seized to settle hefty bills. EMS leaders say the measures are needed to cover their costs because insurers often underpay.
by Michelle Crouch and Charlotte Ledger
June 16, 2025
 
https://www.northcarolinahealthnews.org/2025/06/16/ambulance-companies-collect-millions-by-seizing-wages-state-tax-refunds/
 
When Christy Owca’s 17-year-old son flipped his Jeep in a crash in 2019, she was grateful that an ambulance got him to the hospital quickly and that his injuries turned out to be minor. So when the first bill from Gaston County’s ambulance agency came, she didn’t think twice about paying the $61 fee.
 
But more bills kept coming. Then came statements from her health insurance company, each showing a different amount she owed just for the ambulance ride.
 
Confused, Owca began making calls — to Gaston Emergency Medical Services, to her health insurance company, to supervisors at both places. She said she spent hours making calls over several months trying to get the situation sorted out. Each time, a representative assured her the issue would be resolved.
 
The bills and notices kept coming. 
 
Then, one day while she was at work, something mortifying happened: She was notified by her company’s human resources office that her wages were being garnished for an unpaid medical bill — that ambulance ride.
 
“It was a total shocker and extremely embarrassing,” said Owca, who got the garnishment removed after she sent a complaint to the N.C. Attorney General’s Office about the incident. “If you need an ambulance, if you have a car accident or another emergency, you shouldn’t have to worry that they’re going to take your wages if you call 911.”
 
Powerful collection tools
Because most EMS agencies in North Carolina are government entities or government-affiliated, they have access to two powerful debt collection tools:
 
Wage or bank account garnishment: State law allows EMS agencies to take up to 10 percent of a person’s paycheck each month or to garnish an unlimited amount from a bank account in their name.
 
State tax refund seizure: Through the state’s “debt setoff” program, EMS agencies can intercept your state tax refund or lottery winnings. In 2024 alone, Mecklenburg County’s EMS provider, MEDIC, collected $2.5 million through the program — more than any other public agency in the state. (More than 500 N.C. public agencies made these collections last year, here’s a list of how much was collected by each.)
 
For ambulance agencies facing budget gaps and rising costs, these tools offer a crucial source of revenue and a way to recoup unpaid bills when costs are rising. EMS leaders say they’re forced to go after patients because insurance companies deny or underpay emergency transport claims.
 
Patient advocates respond that the practices are out of step with efforts in North Carolina and across the country to reduce the aggressive collection of medical debt. In 2024, the state’s hospitals agreed to a medical debt relief plan that prohibits them from using liens, wage garnishment or tax refund seizure to collect medical debt.
 
“People should not be pushed to suffer financially because they needed help at a critical time,” said Rebecca Cerese, health policy advocate for the NC Justice Center. “These types of punitive policies keep people from calling an ambulance when they need one.”
 
Two steps to take your paycheck
Unlike other states, North Carolina does not require ambulance agencies to get a court order to garnish wages or seize funds from a bank account, said Christopher McLaughlin, a professor at the UNC Chapel Hill School of Government who has studied policies related to government debt collection.
 
Instead, he said, N.C. law requires just two pieces of paper: a letter to the debtor notifying them of the garnishment and a notice to the employer or bank directing them to seize the amount owed.
 
It’s the same process that counties and cities can use if you don’t pay your property taxes, he said.
 
“They don’t need to go to court. They don’t need to get approval from anybody,” McLaughlin said.
 
The debtor can stop the garnishment only if they can prove that the agency has the wrong person or they can prove they already paid, McLaughlin said.
 
It’s not clear how many EMS agencies across the state use wage or bank account garnishment or how much they collect, but McLaughlin said he thinks most do.
 
$21M seized from tax refunds and lottery winnings
As for debt setoff, 469 government entities — including counties, cities and utilities — used it to collect $21.4 million from people’s North Carolina tax refunds and lottery winnings in 2024, according to a clearinghouse that helps agencies use the program.
 
Representatives for Wake County EMS and MEDIC — which serve the state’s two largest counties — told The Charlotte Ledger/NC Health News they use the debt setoff program, but they do not pursue wage garnishment.
 
MEDIC considered using wage garnishment in 2019 to address a budget shortfall but dropped the plan after public outcry.
 
A tactic of last resort
Gaston County spokesman Adam Gaub said he could not comment on a specific patient’s bill, citing privacy laws, and he declined a request for an interview about the county’s ambulance billing policies.
 
In a written response to questions, Gaub said Gaston’s ambulance service, known as GEMS, uses a sliding fee scale and does not garnish wages or seize refunds from patients who cannot afford to pay.
 
He emphasized that the agency uses wage garnishment and debt setoff only “as an absolute last course of action” after working with individuals and offering payment plans.
 
The agency’s policy is to send three bills over 90 days before turning a bill over to collections, which triggers the wage garnishment process. The county also sends certified letters to the patient and their employer notifying them of the garnishment.
 
GEMS collected $31,757 in wage garnishments and $244,168 from the debt setoff program in 2024.
 
The agency is already operating in a deficit, Gaub said. In 2024-25, GEMS brought in $16.6 million and spent $23.1 million, with the difference made up by the county’s general fund revenues, which includes property taxes.
 
“Not collecting for services rendered from those who have the capacity to pay would place an additional burden on Gaston County taxpayers and/or would negatively affect our ability to provide our current level of service,” Gaub wrote.
 
What happened to my tax refund?
In Charlotte, Mae Cynthia Glover was caught off guard in 2020 when the state tax refund she was expecting never arrived. Instead, she said she received a letter saying MEDIC had seized it to cover an unpaid ambulance bill.
 
The letter said her refunds would continue to be garnished every year until her full balance was paid, Glover recalled.
 
“It wasn’t much, but it would have been better than nothing,” she said.
 
The unpaid bill dated back to 2019, when Glover finished a week of double shifts at her job as a catering company dishwasher and began feeling dizzy and nauseous. Her sister urged her to call 911. Moments later, in the back of the ambulance, Glover’s heart stopped. Paramedics revived her with a defibrillator, and doctors later implanted a pacemaker.
 
Glover doesn’t remember the exact amount of the ambulance bill — only that it was in the thousands and she couldn’t pay it.
 
She set up a monthly payment plan with MEDIC, but she said she fell behind after her health forced her to stop working. The unpaid bill was sent to collections, triggering the tax refund seizure.
 
“It’s frustrating because you ain’t got no choice when you call the ambulance,” she said. “It’s usually a life-or-death situation.”
 
She said she was relieved when she turned 65 last year and got on Medicare, so she doesn’t have to worry anymore about a big bill if she calls 911.
 
Ambulance providers say they wish they didn’t have to use collection actions like debt setoff and wage garnishment, but they have little choice because of how insurance companies handle emergency transport bills.
 
Medicare and Medicaid reimbursement rates are so low they don’t even cover the cost to run an ambulance, said Regina Godette-Crawford, a lobbyist for the North Carolina Association of EMS Administrators. And private insurance companies routinely underpay or deny claims because they often treat ambulance transports as out-of-network.
 
That leaves the patient responsible for the balance, sometimes totaling in the thousands of dollars.
 
In addition to low reimbursement rates, ambulance services are also grappling with rising costs, workforce shortages and increasing numbers of calls.
 
John Peterson, executive director of MEDIC, said the agency makes every effort to work with patients, offering financial aid to low-income patients and interest-free payment plans. The agency also sends “multiple letters, multiple correspondences” before taking action, he said.
 
He said MEDIC uses the debt setoff program only when patients don’t respond to repeated billing attempts.
 
“If we don’t hear from anybody, then … we have to do what any good agency or business would do, and try to collect those dollars wherever we can,” he said. “We are a safety-net provider, but we’re also a business. We have to be good stewards of taxpayer and patient dollars.”
 
MEDIC gets an annual subsidy from Mecklenburg County’s general fund, which is supported by property and sales taxes. The subsidy is expected to remain flat for 2025-26 at $22.5 million. The new county budget also includes $7.6 million for one-time capital purchases like new ambulances and equipment.
 
Other states have protections
In North Carolina, legislation unanimously approved by the state house aims to ease some of the financial pressure on ambulance agencies. House Bill 489 would require health insurers to treat emergency ambulance transports as in-network and reimburse providers at local rates. The proposed legislation says patients should pay no more than $100 per ride.
 
Nineteen other states have approved similar “surprise ambulance bill” legislation. In some states, such as Massachusetts and California, those laws include provisions that ban EMS agencies from using aggressive collection actions like wage garnishment, said Mona Shah, senior director of policy and strategy at Community Catalyst, a national nonprofit that advocates for medical debt protections.
 
Other states take different approaches to shield patients from harsh collection practices, Shah said.
 
In Texas, for example, wage garnishment for medical debt is banned entirely. And in New Jersey, a 2024 law says wages can’t be garnished for medical debt if a person’s income is below 600 percent of the federal poverty level — currently $192,900 for a family of four. That law specifically names ambulance services as subject to its provisions.
 
“While there are broader policies around hospitals not being able to garnish wages, there can be loopholes for ambulance companies,” Shah said.
 
It’s particularly troubling for a government ambulance agency to be garnishing wages, she said, because it jeopardizes a person’s economic stability for an emergency they couldn’t control.
 
“You expect your government to be there to help in times of emergency,” she said.
 
She added that the real problem lies with insurers failing to cover emergency ambulance bills in the first place — shifting the financial burden to local governments and, ultimately, patients.
 
“We should really be going after insurance companies for denying coverage,” she said, “not patients who call 911 because they have a medical emergency.”

We are honored to share that AIMHI is now part of the Modern Medicaid Alliance. 

The mission of the Alliance is to educate policymakers and the public about the benefits of Medicaid to the American people in terms of cost savings, health outcomes, and social impact.

The alliance highlights how Medicaid is innovating in the delivery of care – especially for America’s most vulnerable citizens – and accountability of the program.

AIMHI Excellence in EMS Integration Award Winners Announced

 To Be Recognized at the AAA Annual Conference & Trade Show

Mechanicsburg, PA—The Academy of International Mobile Healthcare Integration (AIMHI) is excited to announce the winners of the 2025 AIMHI Excellence in EMS Integration Awards. These prestigious honors celebrate agencies, people and programs that integrate high-performance, high-value EMS into the overall healthcare system.

2025 Award Winners are:

• Excellence in EMS Integration Award: Jackson Care Connect, Oregon
• Advocacy in Integrated Healthcare Award: Nye Strategies Communications Firm, Virginia
• Excellence in Public Information or Education: Riggs Ambulance Service, California
• Excellence in Value Demonstration or Research: Prisma Health Ambulance Service - Mobile Integrated Health
• Leadership in Integrated Healthcare Award: Chip Decker, Richmond Ambulance Authority
• 2025 Legislator of the Year: Rep. Jason Smith, Chairman of the House Ways and Means Committee

2025 Honorable Mentions include:

• Nevada Hospital Association
• St. Charles County Police Department
• Tele911

“The 2025 Excellence in Integration Award winners represent the very best in mobile integrated healthcare. We are proud to honor these exceptional programs and individuals,” said AIMHI President Rob Lawrence.

This year’s winners will be celebrated at the American Ambulance Association Annual Conference & Trade Show in Lexington, KY on June 21, 2025.

Click below for a full description of the award winners, and notable honorable mentions.

2025 Awards Summary.pdf

It is increasingly crucial that EMS agencies, and their stakeholders, pay close attention to legislative initiatives that could impact reimbursement for ambulance services.

We recommend active engagement with professional associations advocating for appropriate reimbursement for vital ambulance services!

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Senate GOP proposes bigger Medicaid cuts than House

By: Michael McAuliff

June 16, 2025 06:03 PM

https://www.modernhealthcare.com/politics-regulation/mh-one-big-beautiful-bill-senate-provider-tax/

Senate Republicans are eying even deeper Medicaid cuts and stricter limits on the provider taxes states use to finance the program under legislation introduced Monday.

The House-passed version of the One Big Beautiful Bill Act of 2025 would establish a moratorium on new provider taxes. The Senate Finance Committee portion of the upper chamber’s bill would go further by ordering the District of Columbia and the 40 states that expanded Medicaid under the Affordable Care Act of 2010 to reduce their provider taxes.

States tax providers to help raise their share of funding for the state-federal health program for low-income people. Providers tend to come out ahead because this financing mechanism enables states to maintain Medicaid benefits and reimbursements.

The catch is states may only pay back up to 6% of a provider’s revenue in what’s known as a “safe harbor.” Rather than freezing provider taxes at 6% and barring new ones, as the House bill would do, the Senate measure would start rolling back the safe harbor in 2027 and cap it at 3.5% in 2031.

The nonpartisan Congressional Budget Office has not evaluated the new legislation. But the nonpartisan health policy research institution KFF previously estimated that restricting the provider tax “safe harbor” to 5% would reduce federal spending by $48 billion over 10 years and that limiting it to 2.5% would cut expenditures $241 billion.

The Finance Committee similarly targets so-called state-directed payments in Medicaid expansion states. States utilize this policy to set minimum provider reimbursements for Medicaid managed care insurers. Under the Senate measure, those payments could not exceed Medicare rates in expansion states, while the remaining 10 states could set payments up to 110% of Medicare.

The Senate bill notably doesn’t include an increase in Medicare payments to physicians.

In a news release, Finance Committee Chair Mike Crapo (R-Idaho) does not address the healthcare provisions but said the legislation could change as Congress strives to deliver it to President Donald Trump by July 4.

“I look forward to continued coordination with our colleagues in the House and the administration to deliver President Trump’s bold economic agenda for the American people as quickly as possible,” Crapo said.

The chief purposes of the bill are to extend tax cuts Trump enacted during his first term and to slash spending across the government, which a particular emphasis on healthcare programs. According to the CBO, the House bill would cut healthcare funding by more than $1 trillion, with more than 80% coming from Medicaid.

Finance Committee ranking member Ron Wyden (D-Ore.) slammed the Senate bill in a news release. “The House Republican version of this bill was already a class war, but Senate Republicans decided to inflict even more devastation on the lives of working Americans to give even larger handouts to the top,” he said.

“The biggest winners here are wealthy corporations who would get hundreds of billions of dollars in additional tax breaks on top of what they got in the House Republican bill,” Wyden said. “Senate Republicans would pay for those new corporate tax breaks by making even deeper cuts to Medicaid, slashing funding for rural hospitals and other essential healthcare providers, and throwing cash-strapped states off a funding cliff.”

There is little Democrats can do impede the GOP majority in Congress, which is using expedited procedures under so-called budget reconciliation rules that allow bills to pass the Senate on simple majority votes and don’t permit filibusters.

However, at least four Republicans have raised concerns about Medicaid cuts in recent weeks. The GOP has a 53-47 majority, meaning Majority Leader John Thune (R-S.C.) can afford to lose three votes and still advance the legislation.

Ambulance agencies should continue to work with national and state advocacy associations to monitor the developments related to the One Big Beautiful Bill Act of 2025, as well as CMS’s May 12, 2025 Preserving Medicaid Funding for Vulnerable Populations - Closing a Health Care-Related Tax Loophole Proposed Rule, and the status of the ongoing CMS OIG audits of Medicaid ambulance supplemental payment programs (GEMT).

These developments could have a significant impact on things like payer mixes, supplemental payment programs, and potential Medicare payment reductions through the Statutory Pay‑As‑You‑Go Act of 2010 (S-PAYGO) sequestration provisions.

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GOP tax bill will cost health sector $1T: CBO
Michael McAuliff 
June 04, 2025
 
https://www.modernhealthcare.com/politics-policy/tax-bill-medicaid-cuts-cbo-gop
 
The Republican tax-and-spending-cuts legislation speeding through Congress would take more than $1 trillion out of the healthcare system over a decade, according to an analysis the Congressional Budget Office published Wednesday.
 
The nonpartisan agency's fullest accounting of the House-passed One Big Beautiful Bill Act of 2025 details how President Donald Trump and the GOP-led Congress intend to slash federal spending to partially offset trillions of dollars in tax cuts. In healthcare, Medicaid would be subject to the lion's share of the cuts and see its federal budget diminish by $864 billion. The work requirement provisions alone would reduce spending by $344 billion.
 
The CBO projects that the Medicaid cuts and other policies would lead to 10.9 million people becoming uninsured, including 7.8 million who would lose Medicaid benefits.
 
The estimated Medicaid cuts and the increase in the uninsured are higher than under previous CBO reports because the House made last-minute changes to the measure before sending it to the Senate last month, such as moving the start date for Medicaid work requirements from 2029 to 2026.
 
Most of the healthcare cuts come from the section of the bill authored in the House Energy and Commerce Committee, which total $1 trillion. The House Ways and Means Committee's part of the bill includes several policies targeted at the Affordable Care Act of 2010 that would crimp premium tax credits for migrants and step up eligibility checks for everyone to save about $230 billion. Those provisions account for about 2.3 million people losing insurance.
 
Democrats were quick to blast the bill based on the new score.
 
“We’ve said from the beginning that the numbers would only get worse," Energy and Commerce Committee ranking member Frank Pallone (D-N.J.) said in a news release.
 
“It’s shocking House Republicans rushed to vote on this bill without an accounting from CBO on the millions of people who will lose their healthcare or the trillions of dollars it would add to the national debt," Pallone said. "The truth is Republican leaders raced to pass this bill under cover of night because they didn’t want the American people or even their own members to know about its catastrophic consequences.”
 
Another 4.2 million people would become uninsured if Congress and Trump don't extend the enhanced health insurance exchange subsidies due to expire at the end of the year, according to a separate analysis the CBO presented to Pallone, Ways and Means Committee ranking member Richard Neal (D-Mass.) and Senate Finance Committee ranking member Ron Wyden (D-Ore.) on Wednesday.
 
An additional 900,000 would lose exchange coverage as a result of a proposed rule the Centers for Medicare and Medicaid Services issued in March, which would shorten the annual enrollment period, require stricter eligibility reviews and make other changes to the marketplaces, the CBO reported to the Democratic lawmakers.
 
The combined effects of those policies and the One Big Beautiful Bill Act would result in 16 million more uninsured people by 2024, the CBO concluded.
 
The Senate is working on the tax bill now, with GOP senators holding meetings on how they would like to modify the bill. While nearly every Republican has embraced cutting waste, fraud and abuse in healthcare, some have raised concerns about how deep the Medicaid cuts will be, and have signaled they will listen to constituents to determine if they go too far.

Republican Sens. Susan Collins (Maine), Lisa Murkowski (Alaska) and Josh Hawley (Mo.) have been the most vocally resistant to the steep Medicaid cuts.
 
On Tuesday, Hawley expressed unease in particular about proposed limits on the provider taxes states levy to help finance their share of Medicaid spending, which he described as essential for rural hospitals. Hawley also said he disliked the provisions that would impose cost-sharing requirements on some Medicaid enrollees, dubbing it a "sick tax."
 
"I don't want to see Medicaid benefit cuts in the state, and I don't want to see rural hospitals close," Hawley said.
 
Yet Republicans including Sens. Mike Lee (Utah), Dr. Rand Paul (Ky.) and Ron Johnson (Wis.) are pushing for bigger cuts.

Senate Majority John Thune (R-S.D.) said Republicans are working through the issues, and may identify other possible cuts while satisfying the senators who want to soften the Medicaid provisions.
 
"We have an agenda that everybody campaigned on, most notably the president of the United States, and we're going to deliver on that agenda. And the legislation that was passed by the House will be approved here, strengthened in the Senate," Thune said Tuesday. "When it's all said and done, we'll send it back to the House and hope that they can pass it and put it on the president's desk."