‘We carry a lot of weight’: What rural Mississippi ambulance providers can tell us about America’s broken health care system
Story by Erica Hensley | October 21, 2019
MEADVILLE, Miss. — Driving 80 miles an hour, Tyler Blalock eases off the accelerator and careens his neck to shout over the engine’s roar. “I’ll take it easy over the bridge,” he reassures his partner who’s hunched over bracing himself between two floating medical cabinets while setting up a stretcher and IV in the back.
That narrow, concrete bridge with rusted metal reinforcements casing the top, heads out of downtown Meadville and opens up into Franklin County’s country roads, many of them gravelly, bumpy if not closed to traffic all together.
The sun is starting to set behind heavy storm clouds that have threatened to erupt all afternoon. Blalock wants to get to his destination — a house about 15 miles away — before dusk, because residents don’t label their mailboxes well and they can be easy to miss.
Blalock, a Natchez native and self-described adrenaline junkie, has been in ambulances since 1999. He started his own emergency medical services company in 2010. Over the past two decades, he became increasingly troubled by an industry that prioritizes profits over patients. Specifically, he points to the growing influence of national emergency medical service companies that can dictate the terms of their contracts with local governments and local hospitals, some of which choose to opt out of the trauma care system.
Neither, he believes, is in the best interest of patients.
That’s why he believes he represents an innovative experiment where small independent companies like his can serve as an additional safety net in an emergency medical services industry that includes ambulance companies, health care facilities and local and state governments.
In 2012, the Franklin County Board of Supervisors hired Blalock’s Rural Rapid Response over larger ambulance companies to provide 24/7 ambulance coverage across the rural county because of his personal touch and familiarity with the county’s residents.
“Patients actually matter, they’re not just a number in business and in health care, period,” he said. “The only thing I’m able to compete with [the big companies] against is the quality of the care and the straightforward moral aspect of it, that the patient care is more important than making a dollar. But, I’ve got to make a dollar, because without the dollar I can’t give good patient care.”
Given competition, Medicare reimbursement policies, navigating rapidly deteriorating state roads and bridges and the hospital bottlenecking phenomenon known as wall time, making a dollar is increasingly challenging for small emergency medical services business owners like Blalock, who calls himself a paramedic first and a CEO second.
As a result, these challenges are especially pressing for the rural counties, which often have small tax bases, that rely on his company. Despite the uphill battle, he expanded his operation into Lawrence County last year.
Those low tax bases have to supplement ambulance service contracts to cover emergency transport across their rural counties. Whereas suburban and metro ambulance services struggle to navigate larger populations and their traffic, rural areas struggle to cover the large swaths of land with limited resources — often only one ambulance to cover 700 square miles or more, with further travel to get to an emergency room capable of treating trauma injuries.
More often than not, Blalock takes trauma patients to Jackson. One night after the 85-mile trip last year, he remembers being immediately inflamed as his ambulance rolled to a stop in the emergency bay, when he saw six trucks lined up in front of his.
“It’s instantly frustrating to pull in and see that line and know the hospital accepted your patient knowing how long you’d have to wait,” he said.
By the time he finished his patient’s paperwork and the line of paramedics hadn’t budged, he knew he was in for a long wait. Paramedics dub it wall time — this delay in time between the paramedic arriving at the emergency department and the hospital finding room for the patient.
Blalock’s frustration is two-fold: The delay hurts his patient who’s in pain while waiting for a bed and, possibly, other patients still waiting to be picked up. He got to his patient in time to stabilize her pelvic fracture, but between the scene-treatment, transport back-and-forth and hour-long wall time, he estimates his ambulance was out of commission for five hours — and not getting paid to boot.
During peak hours — from around 11 a.m. to 11 p.m., according to Mississippi Today’s data analysis — ambulances log-jam at emergency departments and are unable to return to service. So, while ambulance service companies may technically have enough staff to meet their county’s emergencies, emergency department wall times burden those staff and response times disproportionate from actual demand.
Blalock says he missed a bad multiple-car rollover wreck that day because he was holed up, standing on the wall. His informal mutual aid agreements kicked in as his backup, but the cycle continued as those ambulances were pulled out of their home county.
“We are a finite resource,” Blalock said. “I can’t do my job because I’m stuck [on the wall] doing theirs.”
Hospital closures across the state put more pressure on the centralized hospital system in Jackson. Hospitals deal with variations in supply and demand of available beds differently, although triage principles prioritize patients based on immediate needs. In Mississippi, University of Mississippi Medical Center is the only Level 1 trauma facility. Paramedics take most major emergencies or cardiac cases, “life or limb” complications as medics say, to UMMC.
As the state-run training hospital, UMMC has the most beds in the state and sees the most patient traffic from ambulance transfers followed by Forrest General in Hattiesburg, Tupelo’s North Mississippi Medical Center, and Jackson-based St. Dominic’s Hospital and Baptist, according to data from the state health department. Because the Jackson-based hospitals have the most space and offer some of the highest levels of care across the state, more often than not, high-need emergency transports end up in the capital city — and that means longer wall times in Jackson, and longer response times in surrounding rural areas.
As rural hospitals close and insurance models change, much government and news media reaction has focused on ambulance response times. Response times usually refer to the amount of time between the 911 call and when the ambulance arrives at the patient’s side.
Multiple variables affect that response time including: when the ambulance gets that call, the distance they must travel to pick up the patients and the number of ambulances available to respond.
But, according to our data analysis, paramedic reports and research, it’s often the wall time — which comes at the tail end of the process — that clogs up the entire ambulance system and lengthens response times across the board. Jackson hospitals have the longest wall time across the state, which costs local and traveling paramedics uncompensated time away from the next 911 call.
Rural areas are often disproportionately saddled with the cost of centralizing care. Maria Bianchi, executive director of American Ambulance Association that represents ambulance services across the country, says the result makes it harder for ambulance services, and the counties who contract them, to make ends meet. She adds that ambulance providers in rural areas also tend to have more people lacking insurance, low call volume and lengthier times on task.
“In rural areas the challenge that we have is it’s also an inverted system because you’ve got to be prepared as an ambulance service provider to respond 24 hours a day, 7 days a week, 365 days out of the year, regardless of whether you get a call or not … but you do need to have a certain level of surge or cost of readiness embedded.
“And unfortunately, especially in rural, super-rural and frontier areas, their reimbursement rate for even the highest levels of care of a medical transport is never going to meet, at least through Medicare or Medicaid, the actual cost of providing that service.”
Nationwide, Medicare is the largest reimburser of ambulance service followed by private insurance and Medicaid. Federal protections dictate that emergency services cannot deny a patient based on their insurance status — but if a passenger lacks insurance, more often than not, the ambulance will not be paid for that call.
Average reimbursement for emergency calls ranges from $200 to $300, which is usually less than an ambulance’s costs, depending on the distance and nature of treatment. Research estimates that reimbursement rates are at least 6 percent less than actual costs and more than 70 percent of calls are carried out at under-cost, evaporating profit margins for small companies. The reimbursement rate is set in stone with Medicare and Medicaid as a “transport supply,” not a medical treatment that would reimburse at a higher rate. Private insurers follow the same suit. Emergency medical services advocates argue that the service is tantamount to mobile health care — paramedics stabilize and treat patients on the way to the hospital, just without the time to or benefit of a full diagnosis — and falls into a billing grey area between transport and medical treatment.
Kevin McGinnis has seen every aspect of the emergency medical services business — from the provider perspective, the state and hospital. He currently manages programming for rural emergency medical services with the National Association of State EMS Officials. He says the perennial funding problem stems from having to navigate too small a pool of resources for too big of a need.
“There’s one other thing that’s tying EMS’s wrists behind the back from a funding point of view and that is that (Medicare) has always had an upside down incentive for modern (emergency medical services) in how it pays EMS … based on a 1960s model where we were horizontal taxi cabs and all we did was transport patients,” he says, when many EMS were staffed by volunteers, and reimbursement was designed to just keep systems afloat.
Because ambulance services are regulated and reimbursed more like medical supply companies or buses, rather than medical providers, they have to take a patient to a hospital to get paid. In what advocates argue is an inverse incentive in modern health care that has morphed to prioritize treating patients in place, EMS are burdened with uncompensated time if they keep a patient who doesn’t need to go to the hospital out of the ER.
According to advocates, the model causes cyclical problems for the business side, like trouble attracting and keeping good medics. Essentially, the risk is high, but the benefit is low.
“Here’s the bottom line: If you don’t pay adequately, you’re going to have recruitment and retention problems within your workforce. If you do not receive adequate revenue, you’re going to be unable to pay your workforce adequately,” McGinnis said. “If on top of all of that, your history is deeply bound in the foundation in volunteerism, you’re set up from Day One to have problems with the other two.”
For Blalock and many of the other 2,100 emergency medical technicians and paramedics across the state, the low reimbursement and as they see it, lacking respect — they bristle at the term “ambulance driver” — is a big source of frustration and worry. The reimbursement rates aren’t enough to make ends meet, much less bolster an industry plagued with recruitment and retention issues.
“In Franklin County, with 8,000 residents, I can’t run enough calls to break even. They subsidize me with a certain amount every year … I actually competed against AMR when I got this contract. So to go up against the world’s largest ambulance company and to prevail, there’s no reason I should be in business,” Blalock said.
Due partly to those recruitment issues, Mississippi averages about seven emergency medics for every 10,000 people. Funding structures to secure the safety net are fragmented and sparse. No Mississippi law mandates counties to supply or fund emergency medical services, although all have some type of coverage. But how they fund and regulate that emergency service is largely up to supervisors and their budgets.
The health department regulates permits and equipment, but does not oversee any performance-based accountability, like response times. The state’s trauma fund, which Jackson-based Baptist and St. Dominic’s pay into to avoid accepting high-need trauma patients, kicks 15 percent of its annual budget to counties based on population counts for the sole purpose of aiding ambulance service. But, it’s barely a drop in the bucket to cover the around $800,000 needed yearly to run just one truck. Additionally, the Legislature recently reduced the health department’s spending power and swept the dedicated trauma fund into the state’s general fund, which equaled a $2 million cut to the trauma system last year, though it’s fluctuated since.
The trauma fund allocation varies from around $4,000 for the most rural to $90,000 for Hinds County, the state’s most populous. Franklin County pays Blalock’s Rural Rapid Response an annual subsidy to respond to 911 calls. Due to budget cuts last year, the county cut his subsidy down by more than a third, to $140,000.
“I’m absorbing that cost. I’m borrowing money and they’re going to slowly get me back to full funding over the next three years, but until then I’m basically working for free … I don’t know what answer there is. We are pushing it onto the smaller governments who aren’t equipped to do it because they can’t afford to fix the bridges that are out all across the state, let alone subsidize ambulance service.” Franklin County made good on their promise and recently re-upped his subsidy by $25,000 for the next year. It helps, but it’s still made for a tough time, he says. “This has been my hardest year ever,” he said, but not for lack of lessons learned. If he faces a cut subsidy again he’ll walk away, he says, “I’ll have to just close up shop.”
Over the past decades, ambulance services have been asked to do more with less. Regulations are scattered across agencies and increasing as medical technologies and care systems grow, but reimbursements and EMS wages are stagnant. Mississippi EMTs and paramedics make around $33,000 a year, according to the Bureau of Labor Statistics.
“I don’t know how I’m in business,” Blalock says, as he prepares for another 24-hour shift to give his staff time off in hopes of saving them from burnout and himself from the high cost of turnover.
“I can’t do this forever,” he says. “[The job] wears on your conscience, and there’s things you can’t unsee.”
At quarterly state EMS Advisory Council meetings, he advocates for more mental health resources, like psychiatry evaluations and therapy, and more support from the state. He wants to offer his staff resources, rather than react when the pressure mounts. Though talks of grant proposals are mentioned, as of this summer no formal support network is in place for paramedics across the state. A bill to address health care needs among first responders that was signed into law this year, does not include paramedics or EMTs.
“We carry a lot of weight, and it gets heavier over time,” he said. “It’s a big problem and nobody pays attention to us. I feel like I’m the little dog just yapping sometimes, just saying, ‘Hey look at me, look at me,’ but the squeaky wheel gets a little oil.”