Private EMS Companies-Their Biggest Problem?

FirstResponder

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What is the single biggest problem in private EMS? There are plenty of places to point your finger when asked "what's wrong" with private EMS. Private ambulance services, in particular, is the subject in question. Regardless of the diverse professions we come from within the medical field, it's safe to assume that almost everyone in the medical field has had some form of experience with private EMS. That's what makes this topic even more worthy of a discussion. There needs to be ideas from different perspectives being thrown into the mix when it comes to addressing the problems in private EMS. There are healthcare professionals who work in an ED, for example, that have made particular observations about this area of EMS. Others, who work in a SNF, for example, might have an entirely different perspective. So on and so forth. Those of us in EMS can't work to fix the problems we see on a regular basis if we can't understand other professional perspectives. Yes, there are plenty of problems to point out and this is true for every profession. It's not EMS-exclusive. But...the biggest problem?
What's the biggest problem in private EMS? Where do you see the most significant areas of concern?
 

RocketMedic

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$. Private 911 EMS is trying to exist in a market that generally doesn't have it, has to get it from entities that don't like to spend it, and are driven by it.
 

DesertMedic66

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As was already stated the biggest issue IMO is money. Take for instance my company. We are a private 911 company with a county contract.

Money issues:
A lot of uninsured patients who won’t/can’t pay.
Insurance reimbursement rates are crap.
We are not funded through taxes and can’t add in a new proposition for more money.
We pay the county money in order to keep our contract (in the millions of dollars).
We have late fees if we don’t make our scene times and we also have hardly any exceptions (max single fine is $10,000 per call).
By having the county contract the county also put in that we have to transport all 5150 (psych holds) and will probably not get paid for them.
All new ambulances must be type 1 or 3 even though we ordered 10 brand new type 2s.
All major equipment must be replaced every 5 years (radios, MDTs, computers).
We must do X amount of no cost things for the county.
We must have additional certs over any other responder in the system.
The list keeps on going and can get very specific.

With the low reimbursement rates and all the fees we have to pay the county it really starts to add up. If we did not do a lot of event medical coverage I highly doubt our company would be able to stay afloat.
 

FirstResponder

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As was already stated the biggest issue IMO is money. Take for instance my company. We are a private 911 company with a county contract.

Money issues:
A lot of uninsured patients who won’t/can’t pay.
Insurance reimbursement rates are crap.
We are not funded through taxes and can’t add in a new proposition for more money.
We pay the county money in order to keep our contract (in the millions of dollars).
We have late fees if we don’t make our scene times and we also have hardly any exceptions (max single fine is $10,000 per call).
By having the county contract the county also put in that we have to transport all 5150 (psych holds) and will probably not get paid for them.
All new ambulances must be type 1 or 3 even though we ordered 10 brand new type 2s.
All major equipment must be replaced every 5 years (radios, MDTs, computers).
We must do X amount of no cost things for the county.
We must have additional certs over any other responder in the system.
The list keeps on going and can get very specific.

With the low reimbursement rates and all the fees we have to pay the county it really starts to add up. If we did not do a lot of event medical coverage I highly doubt our company would be able to stay afloat.
Interesting perspective with "county contracts." Also, I'm curious if anyone else feels that transporting psych holds can tie up resources. For example, many town contracts require just one dedicated ambulance (usually double ALS). If a 911 call comes in for any psych-related emergency, that can sometimes tie up resources for way too long. A BLS call in nature might take the only ALS unit out of service for an extended period of time because they are spending so much time on scene and in transport. Maybe this is an EMD issue more than it is an issue in the field, however, it definitely has a contractual component to it.
 

DrParasite

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Money issues:
A lot of uninsured patients who won’t/can’t pay.
Insurance reimbursement rates are crap.
all very true
We are not funded through taxes and can’t add in a new proposition for more money.
everyone wants something for nothing, and then *****es when they don't get the server that they don't pay for fast enought
We pay the county money in order to keep our contract (in the millions of dollars).
this is actually bad business, especially in a field like 911 that tends to lose money on a regular basis. however it seems to be the norm in many areas, and also contributes to why a different private takes over 911 EMS every so often when the predecessor say it can't function without enough money. it's a vicious cycle, really.
We have late fees if we don’t make our scene times and we also have hardly any exceptions (max single fine is $10,000 per call).
now that's impressive. you would think that the solution to not making scene times is more units..... but that's a different story.
By having the county contract the county also put in that we have to transport all 5150 (psych holds) and will probably not get paid for them.
sounds like someone didn't negotiate right, or was willing to accept this loss to get the contract
All new ambulances must be type 1 or 3 even though we ordered 10 brand new type 2s.
that's your company's stupidity for ordering 10 new ambulances that you can't use. blame a stupid manager/administrator, not the system.
All major equipment must be replaced every 5 years (radios, MDTs, computers).
this is actualy a really good thing: if this rule wasn't in place, we both know there would be some company that would be using ambulances from the 1990s, and barely functioning radios (and we both know that MDTs and computers wouldn't exist). Remember, the less money a company has to spend, the more it's profits are.
We must do X amount of no cost things for the county.
goes back to something for nothing
We must have additional certs over any other responder in the system.
do you pay for that or does your company? because my agencies have always exceeded the bare minimums.

The biggest problem I see in private, for profit, EMS is you are doing everything you can to make money, without spending any money unless you absolutely have to, in an industry where you must provide service to 100% of the population with a 0% guarantee that you will ever get paid for the services rendered. And then you throw in the bribes that you need to give (oh, we will pay your town/county XYZ amount of dollars if you will select us as the provider the service, to be surprised, I'm surprised the mob hasn't gotten into private ambulance service), and rely on the revenue from the people who you need to serve but don't need to pay for the services, and you see where issues arise.
For example, many town contracts require just one dedicated ambulance (usually double ALS). If a 911 call comes in for any psych-related emergency, that can sometimes tie up resources for way too long.
it doesn't matter what happens; if a 911 call comes in for anything, it ties up that ambulance. what happens when a second call comes in? or a third? the contract calls for 1 dedicated ambulance, but the agency is the 911 provider for the town. What happens if the primary call is for a drunk person who needs to go to the hospital, and while they are transporting, a 2 year old stops breathing and the responding units have an extended ETA? the town blames the ambulance company, since they are the contracted provider, goes to the media and press blaming them, even other public safety agencies say "we called for EMS, they took a long time." the fact that the company followed the contract is lost to the general public; because this public relations nightmare (and the incident that caused it) was totally the fault of the town's leadership.

you want to fix EMS? follow these steps:
1) for any given area, you have as many BLS ambulances as you have staffed fire engines; you have as many ALS ambulances as staffed ladder companies and heavy rescues
2) ems need guaranteed money to function, so they should be tax supported, just like FD and PD, which spends millions every year, and are known black holes for money. this ensures EMS has the funding for new equipment, new trucks, and decent salaries for their staff
3) change the perception that EMS is a get something for nothing service. if you want quality service, you need to pay for it. if you don't want to, than expect crappy service. you get what you pay for.
4) take private EMS out of the 911 system. it doesn't make money, unless you short change something (often the employees). they can handle all the IFTs they want, where they can guarantee payment before the services are rendered. It's also harder to regular private IFTs, compared to government or quasi government agencies, at least when it comes to hiring standards, background checks, and QA/QI. There are exceptions, but we ALL know of private EMS agencies that will hire anyone with a card and a pulse, and the pulse is optional.

the EMS system, in general, is so broken, that people don't even realize it; they just accept it as the norm.
 

NPO

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Paying for the privilege to provide service is a racket. The county should be praying you.

The private I used work for did very well financially. It was no secret that the boss poured money into everything (except salary) well beyond the minimum. Their biggest shortcoming was management... Poor management that was disconnected and disinterested in the employees.

Currently I work for a 3rd service that replies on tax and use fees. This is the best model IMO. We are almost exactly funded 50/50 by a 0.25% sales tax and transport fees. As a result, our fees are so low, they're almost affordable for many people. (And as a result, we have a higher percentage of people paying their bills)

Our average charge for an ALS transport in 2018 is $811, with a collection rate of 50.5%. I don't know how that fairs up against most places, but compared to my previous employer, that's way cheaper and significantly higher collection rates.
 
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johnrsemt

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Privately owned company I work PT for is the only company across 2 state borders: 56 miles east into 1 state. 40 miles west into the state. 50 miles north. 60 miles south. Next closest ambulance is BLS only from a volunteer dept. that has 1 EMT B. So if he is at work we respond there to cover them.
Closest hospitals are 110 miles east or west. 125 miles into Level I, II or III hospitals.

We have 3 trucks in service normally; on a good day (or couple of days) we may have 4 trucks in service. Busiest day they have ever had was 14 runs with 12 transports, 4 of which flew.

We really don't have back fill trucks if we get busy. We can call for helicopters but only if the patient is critical enough to need one. But even to fly can take up to 3 hours. We have driven 40 miles to meet a helicopter before.

Last week I was transporting a cardiac patient, and we stopped at a special event to pickup a patient from a wreck going to the same hospital to keep trucks in service in town.

Makes life interesting
 

johnrsemt

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Besides that problems with privately owned EMS companies are: (I worked at one in Indianapolis for 8 years: and one in the West for 2 years)

>>Money: Drives the employees nuts that they always want to make money, but little rule about business: They need to make money to stay in business.
If they don't make money they can't pay people, they can't buy fuel, they can't repair trucks, they can't buy new or new used equipment. They can't stay in business.
Company I worked for in Indy had a couple of small town or small county 911 contracts: I think the most they got from them was $25,000 a year from tax base. Then what ever they could collect from runs. They had to keep at least 2 trucks in county: 1 BLS 1 ALS. If you think about that that is about $200K in payroll.
911 transports pay very little (some areas, mainly big cities ambulance companies are lucky to get 10-20% of runs paid for).
Private runs (ECF to Dr appointments, etc) make better money: depending on insurance. I think we made $88 on Medicare transports. No mileage, just $88.00.
Pay raises are the same: tough to get pay raises.
We got lucky and got contract with the state to do prisoner runs: small hospital to large county hospital (in Indy) Transports with state prisoners (or prison to Central county hospital). Good money there, state actually paid decently.

>> Equipment; hard to buy new trucks when you aren't making a lot of money. Our average truck was purchased with 200K miles on them, we had a couple with over 400K miles on them.

>>People: usually new EMT's and medics straight out of school: not a lot of experience. Good way to get experience if you take the job to learn from it. But most people don't think they can learn working Private.
 

hometownmedic5

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Commercial EMS is a business, thus to stay in business, its main focus has to be profitability. A municipal service or any variety of population funded service can put community altruism before money, if they receive a budget commensurate with the cost of providing the service, but if a commercial service doesn’t generate a net profit(and one the ownership is happy with) they will cease to exist.

Everything else thats wrong with this example or that example of ‘bad privates’ stems from this fundamental fact. If they didn’t have to worry about money, a company could spend more time(money) on training and CQI. More employees could be hired so each would do less work and have a higher job satisfaction, which would in turn increase productivity, longevity, and dedication to the company it self, but privates usually go the other way and run less trucks than they need so everybody does more work and hates life. Better equipment could be purchased to solve a variety of problems, but reimbursement doesn’t go up if you use a power load stretcher instead of a manual, so why spend the money. On and on and on. Almost every problem in commercial EMS can be traced back to money.

Here’s a pro tip for any wannabe EMT’s who might stumble upon this thread, and anybody who hasn’t figured this out for themselves. There are two lies you will likely be told at some point in your career when you’re interviewing for a job in EMS with a commercial service. “Quality patient care comes first. Everything else is secondary” and “We provide the finest equipment and support available on the market”. In commercial EMS, these are almost universally untrue. They aren’t a deal breaker per se, as in all likelihood you’ll be told at least one of these at every interview, but you should know a lie when you hear it and those are two whoppers we hear over and over again.
 

FirstResponder

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Besides that problems with privately owned EMS companies are: (I worked at one in Indianapolis for 8 years: and one in the West for 2 years)

>>Money: Drives the employees nuts that they always want to make money, but little rule about business: They need to make money to stay in business.
If they don't make money they can't pay people, they can't buy fuel, they can't repair trucks, they can't buy new or new used equipment. They can't stay in business.
Company I worked for in Indy had a couple of small town or small county 911 contracts: I think the most they got from them was $25,000 a year from tax base. Then what ever they could collect from runs. They had to keep at least 2 trucks in county: 1 BLS 1 ALS. If you think about that that is about $200K in payroll.
911 transports pay very little (some areas, mainly big cities ambulance companies are lucky to get 10-20% of runs paid for).
Private runs (ECF to Dr appointments, etc) make better money: depending on insurance. I think we made $88 on Medicare transports. No mileage, just $88.00.
Pay raises are the same: tough to get pay raises.
We got lucky and got contract with the state to do prisoner runs: small hospital to large county hospital (in Indy) Transports with state prisoners (or prison to Central county hospital). Good money there, state actually paid decently.

>> Equipment; hard to buy new trucks when you aren't making a lot of money. Our average truck was purchased with 200K miles on them, we had a couple with over 400K miles on them.

>>People: usually new EMT's and medics straight out of school: not a lot of experience. Good way to get experience if you take the job to learn from it. But most people don't think they can learn working Private.
Well said. I think a lot of private companies run into these similar types of problems. Pay raises are definitely a big one, I agree with you there. They're practically non-existent depending on your employer of choice.
 

RocketMedic

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It's more than just private services though. The core issue is that EMS as a whole is trying to make a going concern at working in a market space that does not really exist.

EMS and the emergency medical system is oriented towards a population that is, by definition, a weak consumer. The sick and the young and the old are generally not known for their discretionary spending power, and cultural mandates like EMTALA and the overarching culture of rendering services without regards to ability to pay for them create an environment where we cannot effectively say 'no'. This, in any form, makes it hard to make a going concern with healthcare. Healthcare, as a whole, needs government regulatory infrastructure, financial support and operational guidance.

Private systems (both non-profit and for-profit) actually shine in a lot of contexts, particularly when the local/regional culture and politics don't support a government-run service. North Texas is a great example of this: the fire departments tend to be small and over-extended, with the operational burden of EMS left to non-profit providers or contracted private providers that provide service equivalent to, or even better, than government services could. This is because a lot of their budget (or all of it, in some cases) is shifted off of the local public books. MedStar Fort Worth is probably the penultimate example of this, where they provide consistently high-moderate service in a challenging, high-volume environment that objectively exceeds the services provided by neighboring government organizations (like Dallas Fire-Rescue). A private service can be both fiscally and operationally sound, but it takes a considerable amount of work and arguably some form of government support.

Government-based systems like Keller Fire are fantastic, but then again, those 'good' systems tend to be in small, wealthy enclaves where operational demands are fairly light and funding is lavish. They derail easily when the demand skyrockets and funding stagnates- see Houston Fire, Detroit, or Durham County for examples of how leadership and funding can engulf any entity.

Nationalized systems like the NHS? Great in concept, until a conservative government gets into power and slashes budgets. Why? Same reason- the market space is artificial, needs government intervention (regulatory, financial and operational) and no one really thinks about it until it's expensive.

Honestly, if you want to see a 'perfect private' system IMO, look at CA. As long as transport is the reimbursed part of EMS, staffing the transport vehicle as cheaply as possible makes a boatload of sense; even if one 'only' bills at a BLS rate for everything, you'll still profit off of your EMTs and their labor and there's not a massive demand for 'more' or 'better' training, medicine or equipment coming out of their budgets. This could even result in higher pay for the EMTs. Conversely, the 'expensive' parts of EMS- the high-cost capital, the medications, the expensive-to-train-and-retain paramedics- can be offloaded onto the taxpayers as a whole, and operated at a loss.
 

Qulevrius

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Paying for the privilege to provide service is a racket. The county should be praying you.

Their biggest shortcoming was management... Poor management that was disconnected and disinterested in the employees.
In major urban areas, this is the norm. The privates are tearing each other apart for a chance to push gurneys for county/municipal FDs, because these always pay for transports (however little). Otherwise, it’s tearing each other apart for hospital contracts, with the hospitals twisting their hands with lowball fees. It’s a supply vs demand thing.

As for the management, that’s a chronic, systemic issue. No investment is made in bettering the management, as long as they can bully the employee into submission. And the bigger the company, the worse it is.
 

Bullets

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>>Money: Drives the employees nuts that they always want to make money, but little rule about business: They need to make money to stay in business.
If they don't make money they can't pay people, they can't buy fuel, they can't repair trucks, they can't buy new or new used equipment. They can't stay in business.
This is the biggest issue i try and get my staff to understand. Would i pay them all $22/hr? Sure, but they also want new trucks with every whizz bang gizmo, power lift everything, Lucas devices, electric combi tools, new toughbooks, new radios, ect. Which do i spend my money on?
 

FirstResponder

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In major urban areas, this is the norm. The privates are tearing each other apart for a chance to push gurneys for county/municipal FDs, because these always pay for transports (however little). Otherwise, it’s tearing each other apart for hospital contracts, with the hospitals twisting their hands with lowball fees. It’s a supply vs demand thing.

As for the management, that’s a chronic, systemic issue. No investment is made in bettering the management, as long as they can bully the employee into submission. And the bigger the company, the worse it is.
unfortunately that's usually the case
 

Phillyrube

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I worked for a hospital based EMS service, only 5 trucks, but we doubled as ED techs, emergency management and MCI. We had just started doing community medicine, following up on 'problem' patients, documenting failures to followup or fill prescriptions. Contracted with a couple other local companies plus that alphabet soup agency to do transports. Main reason the hospital kept us was, it's cheaper to turf a patient than keep him in a floor bed for another day. I did some of the billing and it cost the hospital $200 more per patient with another agency. Hospital sold the trucks and noname took it over this past spring.

Now, we bragged we hired the best, and I think we did. All experienced ALS and CC techs, mostly from local FDs part time. As hospital employees, when we went to the floor, and the charge is trying to get paperwork together for 3 transfers, and the call bells are going off, we'd jump in and work until we got our patient. Change beds, change patients, do whatever it took so the staff could finish up the process so we could leave. Floor nurses really appreciated it. We worked there, it was courtesy. Private agencies would just stand around complaining it was taking too long, playing with their phones or raiding the fridge in the staff lounge. Lots of documented complaints.

With the takeover, it has really gotten worse. With the usual staff shortages on the floors, a few extra hands to help out are no longer there.
Seems nurses don't forget a face, so when certain crews would hit the floor, it took an amazingly long time to get their stuff ready. It was that way before, but amazingly we'd be shuffled to the head of the line.

Is this right? Probably not, but human nature is human nature. Many years of working with nurses told me never to mess with them.
 

johnrsemt

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When I worked busy private service; or FD; We would clean a room (nurse would tell us patient will go to room 10 as soon as we can clean it); we would park pt in hall with 1 crewmember, other crew would clean room, and make bed. Move the patient to the bed. 1 would report room clean to the nurse. Faster turn around.
My partners and I could do 3 or 4 runs in the time that other crews would wait for a room for their patient.
Discharges from the floor, we would do vital signs, and report them to the nurse, so they could put them in their discharge notes and we could put down 1st set for our reports.
Make the nurses happy, they remember when they need to call for transports
 

DrParasite

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Paying for the privilege to provide service is a racket. The county should be praying you.
I've never heard of this concept outside of on emtlife. it sounds like bribery to me. But if the privates are willing to do it, is there any question as to why they

a few extra hands to help out are no longer there.
While I'm sure the assistance was appreciated, it's literally winning the battle but losing the war, especially when those few extra hands disappear. The staff begin relying on you to make the operation go smoother, which it does, so upper management doesn't need to budget for more staff, because those extra hands are always there.

when certain crews would hit the floor, it took an amazingly long time to get their stuff ready. It was that way before, but amazingly we'd be shuffled to the head of the line.
So your nurses are intentionally delaying the discharge, making things fall even further behind, and making everyone work harder, and patient's wait even longer? they are a huge part of the problem then.

Am I nice to nurses? absolutely. I'll help out when I can, but I also know that there is a fine line between my job and their job. And yes, there is a certain blonde who would get a special delivery from Dunkin Donuts if she asked me for one. I can help them out, but I never had a nurse help me clean up my disaster of a truck following a messy call. Never had a nurse meet me in the ER bay to assist with CPR because our patient coded enroute to the hospital. Have had several nurses give me dirty looks when I took extra thick blankets from the ER cache during those sub freezing nights, especially when the EMS cart was empty.

ER or hospital staffing is not an issue that EMS should be fixing, unless EMS is part of the hospital, and their assigned task is to assist with staffing. If EMS is being used to free supplemental staffing to an understaffed ER, than there is 0, none, nada, incentive for the ER upper management to staff accordingly, and give the ER more money to hire more personnel.

and everything @hometownmedic5 said in his post was 100% spot on
 

FirstResponder

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I've never heard of this concept outside of on emtlife. it sounds like bribery to me. But if the privates are willing to do it, is there any question as to why they

While I'm sure the assistance was appreciated, it's literally winning the battle but losing the war, especially when those few extra hands disappear. The staff begin relying on you to make the operation go smoother, which it does, so upper management doesn't need to budget for more staff, because those extra hands are always there.

So your nurses are intentionally delaying the discharge, making things fall even further behind, and making everyone work harder, and patient's wait even longer? they are a huge part of the problem then.

Am I nice to nurses? absolutely. I'll help out when I can, but I also know that there is a fine line between my job and their job. And yes, there is a certain blonde who would get a special delivery from Dunkin Donuts if she asked me for one. I can help them out, but I never had a nurse help me clean up my disaster of a truck following a messy call. Never had a nurse meet me in the ER bay to assist with CPR because our patient coded enroute to the hospital. Have had several nurses give me dirty looks when I took extra thick blankets from the ER cache during those sub freezing nights, especially when the EMS cart was empty.

ER or hospital staffing is not an issue that EMS should be fixing, unless EMS is part of the hospital, and their assigned task is to assist with staffing. If EMS is being used to free supplemental staffing to an understaffed ER, than there is 0, none, nada, incentive for the ER upper management to staff accordingly, and give the ER more money to hire more personnel.

and everything @hometownmedic5 said in his post was 100% spot on
very interesting perspective... some really good points in there too
 
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