Marcus Daly Memorial Hospital (MDMH) took over Ravalli County’s all-volunteer ambulance service 12 years ago. MDMH modernized it, staffed it, increased it and ran it at a profit for nine years. Now, facing its third fiscal year of the ambulance program running at a loss, the hospital plans to make cuts this spring in both the program and the Emergency Medical Technicians (EMTs) who staff it. That means a slower response time for some ambulance runs and a longer wait for those in need of emergency medical treatment.
Higher demands for services and lower reimbursement costs from Medicaid are the major reasons given by hospital administrator John Bartos for the proposed cuts. According to Bartos, Medicare capped reimbursement for an ambulance run at $150, but that means many runs operate in the red. Depending on the distance of the run and the care administered on-board to a patient, ambulance runs cost from $300 to $800. Medicare is billed for about 60 percent of all ambulance runs, Medicaid for about 5 percent and 35 percent of ambulance passengers either have private insurance or no insurance. Bartos estimated more than 15 percent of the ambulance runs in a given year are not paid for by anyone.
Last June Bartos went to the Ravalli County Commissioners and asked them to consider subsidizing the ambulance service as they did when it was a county-sponsored entity. Faced with dwindling reserves and a budget deficit of $800,000 to $1 million, the commissioners did not respond. By law, they are charged with finding a method to provide ambulance services, but are not mandated to actually provide it.
“We don’t have any extra funds at this time and we have many other emergency services to provide for,” said County Commissioner Jack Atthowe. “Both the county administrative officer and the sheriff are opposed to using county money on the ambulance program.”
Bartos and the hospital board decided program cutbacks were necessary to try to balance the budget, which they say will run $325,000 in the red this fiscal year. Proposed cutbacks are expected to save the hospital about $125,000 annually, but at the same time, Bartos said he does not expect the program can continue indefinitely without taxpayer support.
When MDMH took over the ambulance service, the ambulances were staffed by an on-call, all-volunteer staff, similar to volunteer firemen. Ambulances were available at fire stations in outlying communities and at the sheriff’s office in Hamilton. When an emergency call came in, the dispatch center paged volunteer attendants who responded to the ambulance and then to the emergency. Most ambulance attendants at the time held CPR and Advanced First Aid cards but there were few certified EMTs.
After the privately owned hospital took over, the level of training increased steadily. All 75 Ravalli County ambulance attendants are now Basic EMTs and many are qualified to perform more complicated tasks. Three have passed their paramedic examinations. In Stevensville and Hamilton, ambulance crews gradually became full-time hospital employees. According to Bartos, that became a necessity as local employers grew less willing to have employees leave on an ever-increasing number of ambulance runs.
Crews in Victor and Darby remained part-time, receiving 50 cents an hour for on-call time and only being paid wages when they were actually involved in a run.
Now, in an effort to cut costs, both Stevensville and Hamilton will have on-call periods when no ambulance crews are on duty, starting in May. In Hamilton that will be from 2 a.m. to 6 a.m. and in Stevensville it will be from 10 p.m. to 6 a.m., times when there are fewer calls.
But the proposal has drawn criticism from EMTs who now routinely work a 12-hour shift. It means that the 6 p.m. to 6 a.m. shift will be paid for eight hours and on-call for four hours.
For EMT Tom Hodgetts, who does not live in Hamilton, it means he must find a place to be within five minutes of the hospital for that four-hour period. “There are a lot of us who don’t live in town and this presents a problem,” Hodgetts said. “We end up asking ourselves if it’s worth it to work that shift.”
According to Hodgetts and Lori Rokosh, another EMT who works both in Hamilton and Missoula hospitals, the MDMH ambulance crew routinely performs many other tasks at the hospital when they are not on ambulance runs. They assist in the emergency room, take vital signs on patients in the regular wards, do clerical work and spend a lot of time on maintenance—shoveling snow, pulling weeds, policing the parking lots.
“That time has never been charged to the various other departments and, if it was, it would lower the ambulance crew costs significantly,” Rokosh said. “We’ve been told they are going to keep track of it that way in the future. It needs to be done.”
Basic EMTs must put in a minimum of 24 hours of continuing education each year to retain certification and each of the three additional levels is required to add more training in 24-, 36-, and 48-hour increments. Some of the training is provided without cost by the hospital but the training time is not paid time.
“We are professionals with a high level of training and we give a lot, but now we’re being asked to give even more,” Hodgetts said.
Rokosh, who lives near Stevensville, said she is concerned about the increased response time in the county’s two major urban areas when the new on-call policy is introduced. An average of five to eight additional minutes will be added to each run.
“It seems you’re going backwards instead of staying where you are or going forward,” Rokosh said. “In an emergency every minute counts so much.”