DUTTON, Mont. – Vern Greyn was sitting in the raised saddle of a tractor, cutting the dead branches of a tree, when he lost his balance. He fell 12 feet and hit his head on the concrete patio outside his home in this small farming town on the central plains of Montana.
Greyn, then 58, could not move. His wife called 911. An emergency volunteer medical technician showed up: his daughter-in-law, Leigh. But there has been a problem. Greyn was too big for her to move on her own, so she had to call for help from the ambulance crew in Power, the next finished city.
“I’ve been sitting here for half an hour or so,” Greyn said, recounting what happened two years ago from the same patio. When help finally arrived, they loaded him into the ambulance and took him to the nearest hospital, where they found he had a concussion.
In rural America, it is increasingly difficult for ambulance services to respond to emergencies like Greyn’s. One factor is that emergency medical services are struggling to find young volunteers to replace retired EMTs. Another is a growing financial crisis among rural voluntary EMS agencies: A third of them are at risk because they cannot cover their operating costs.
“More and more volunteer services are finding this unsustainable,” said Brock Slabach, head of operations for the National Association of Rural Health.
Rural ambulance services depend heavily on volunteers. About 53% of rural EMS agencies are staffed by volunteers, compared to 14% in urban areas, according to an NRHA report. More than 70% of those rural agencies report difficulties in finding volunteers.
In Montana, a state Report of the Department of Public Health and Human Services says, about 20% of EMS agencies often have trouble answering 911 calls due to lack of available volunteers, and 34% occasionally are unable to answer a call.
When this happens, other EMS agencies have to respond, sometimes having to drive long distances when a minute delay can be the difference between life and death. Sometimes an emergency call will go unanswered, leaving people to drive themselves or asking neighbors to take them to the nearest hospital.
According to state data, 60% of Montana’s volunteer EMTs are 40 years old or older, and fewer young people are intervening to replace elderly people who volunteer to save the lives of their relatives, friends, and neighbors.
Finding enough volunteers to fill a rural ambulance crew is not a new problem. In Dutton, where Greyn fell out of the tractor bucket, EMS Crew Chief Colleen Campbell says getting people to volunteer and keeping them on the list has been a problem for most of her 17 years. she volunteered with the Dutton ambulance crew.
Dutton’s team currently has four volunteers, including Campbell. In its early days, the Dutton ambulance service was managed locally and survived by limited reimbursement of health insurance and donations. At the lowest point, she said, her crew consisted of two people: her and her best friend.
This made them respond to calls, do the administrative work and organize the necessary training to maintain certifications more than they could handle. In 2011, the Dutton ambulance service was absorbed by Teton County.
That has eased some of Campbell’s problems, but his biggest challenge remains finding people willing to go through about 155 hours of training and take the written and practical tests in this city of less than 300 people.
“It’s just a big responsibility that people aren’t willing to jump on, I think,” Campbell said.
In addition to staff shortages, about one-third of rural EMS agencies in the United States are in immediate operational danger because they cannot cover their costs, according to the NRHA.
Slabach said it stems largely from insufficient Medicaid and Medicare reimbursements. Those reimbursements cover, on average, about one-third of the actual costs of maintaining equipment, stocking medication and paying for insurance and other fixed expenses.
Many rural ambulance services rely on patients ’private insurance to close the gap. Private insurance pays much more than MedicaidBut due to low call volumes, rural EMS agencies cannot always cover their bills, Slabach said.
“Therefore, it is not possible in many cases without significant subsidies to operate an emergency service in a large area with small populations,” he said.
Slabach and others say reimbursement and deepening volunteerism mean that rural areas of the United States can no longer rely solely on volunteers, but must find ways to convert into paid staff.
Jim DeTienne, who recently retired as head of the Montana Department of Health’s EMS and Trauma Systems, acknowledged that sparsely populated counties will also need volunteers, but said he has at least one paid EMT on board. list could be a huge benefit.
DeTienne said he believes EMS should be declared an essential service such as the police or fire departments. Then counties could tax their residents to pay for ambulance services and provide a dedicated revenue stream.
Only 11 states have considered EMS an essential service, Slabach said.
The Montana health department’s report on EMS services suggested other ways to move away from full-time volunteer services, such as whether EMS agencies merge with taxpayer-funded fire departments or whether the hospitals take programs.
In southwest Montana, the city of Ennis, the Madison Valley Medical Center absorbed declining EMS volunteer service earlier this year.
EMS director Nick Efta, a former volunteer, said the transition has stabilized the service, which had struggled to answer every 911 call. He said the service recently had nine calls in 24 hours. That included three patient transfers to larger hospitals miles away.
“In view of that day and how the calls were made, I think in a volunteer model it would be difficult to make all those calls,” Efta said.
Rich Rasmussen, president and CEO of the Montana Hospital Association, said an Ennis-style dam might not be financially feasible for many of the smaller critically ill hospitals serving rural areas. Many small hospitals that take emergency services do so without loss, he said.
“Actually, what we need is a change in federal policy, which would allow critically ill hospitals to be reimbursed for the cost of providing that EMS service,” he said.
Under current Medicare policy, federally designated critical access hospitals can be reimbursed for EMS only if there is no other ambulance service within 35 miles, Rasmussen said. Eliminating this mileage requirement will give hospitals an incentive to take EMS, Rasmussen said.
“It’s a long way to go to do this, but it will dramatically improve EMS access across the country,” he said.
A Center for Medicare and Medicaid Services pilot program attempts to eliminate minimum mileage for emergency services with selected critically ill hospitals.
The rural EMS crunch places a greater burden on the nearest urban ambulance services. Don Whalen, who runs a private EMS service in Missoula, the second-largest city in the state, said his crews regularly respond to peripheral communities 70 miles away and sometimes across the Idaho line because agencies local volunteers often are unable to respond to emergency calls.
“We know if we don’t go, no one comes for the patient, because many times we are the last resort,” he said.
Missoula EMS is responsible for calls in the city and in Missoula County. Whalen said Missoula EMS has agreed with a couple of volunteer EMS agencies in smaller communities to provide an ambulance when volunteers have difficulty leaving work to respond to calls.
Those agreements, in addition to answering other cities where 911 calls are unanswered, take resources from Missoula, he said.
Whalen said communities need to find ways to stabilize or convert their volunteer programs, or private services as he will have financial support to continue to respond in other communities.
But the appetite of lawmakers to find ways to fund EMS is limited. During Montana’s legislative session earlier this year, DeTienne pushed for a bill that would study the benefit from declaring EMS an essential service, among other possible improvements. The bill died soon after.
Back in Dutton, the EMS team leader thinks about his future after 17 years as a volunteer. Campbell said she wants to spend more time with her grandchildren, who live outside the city. If she retires, there is no guarantee that anyone will replace her. She is torn about what she will do.
“My license is good until March 2022, and we’ll see just that,” Campbell said.
Kaiser Health News is a national health policy news service. It is an independent publishing program of the Henry J. Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.