Rural Ambulances Struggle To Respond To Calls As EMS Volunteers Age Out
What if you called 911 for an ambulance and nobody could come? That’s the reality for some rural residents across Montana as emergency medical services struggle to find volunteers. Over half of rural ambulances across the state and country rely on volunteers, and fewer people are responding to pleas from local EMS agencies to replace an aging workforce.
Vern Greyn lives next to his fertilizer business on the edge of Dutton, a central Montana town along Interstate 15 with about 300 residents.
Two years ago, Greyn climbed into the bucket of a tractor to cut some dead branches off the lone tree behind his house. The bucket was a bit wobbly, and he fell about 12 feet onto his patio concrete.
“The fall wasn’t bad. It was the landing that sucked!” he laughs.
He hit his head and couldn’t move. Greyn’s wife quickly called 911, but only one volunteer EMT was available to respond, and without more help they couldn’t load Greyn onto a stretcher.
“I said, ‘ah, get the tractor and load me up,’ but I knew better,” Greyn says.
Greyn had to lay there for about 45 minutes as a neighboring ambulance crew responded, which isn’t unusual in this rural stretch of Montana.
Greyn says there are times when an ambulance simply isn’t available, like when one of his workers cut off some fingers.
“I said, ‘get in the pickup, we’re headed for town.’ You do the best you can with the distance you need to cover,” he says.
Over at the Dutton Ambulance Barn just a mile away, Crew Chief Colleen Campbell explains her crew works under Teton County EMS. In Dutton, she’s one of four volunteers.
“Three of us are in our 50s, one of us is in our 30s. We have no one younger really coming up too much,” she says.
Campbell says finding volunteers has always been hard during her 17 years with the ambulance, but says it’s getting harder as young people increasingly work out of town. At times, it’s difficult for the Dutton crew to respond to the few calls they get each month.
“I think all of us have responded by ourselves at one point in time,” Campbell says.
Waning volunteerism and the graying of volunteer EMTs is a problem for many of Montana’s ambulance services, about three-fourths of which depend on volunteers. A recent report from the state health department found that about 54% of EMS agencies frequently or occasionally have trouble responding to 911 calls due to a lack of available volunteers.
Brock Slabach is the chief operating officer of the National Rural Health Association. He says a majority of rural EMS is grappling with this issue.
“More and more volunteer services are finding this to be untenable. Then you couple that with the reimbursement issues. They’re finding that, even with volunteer labor, [it’s] hard to meet the needs of sustaining their ambulance service,” Slabach says.
According to an NRHA report, about a third of rural EMS agencies in the U.S. are in immediate jeopardy of folding, in part because Medicare and Medicaid reimbursements don’t always cover ambulance service costs. Slabach says while private insurance pays significantly more, there’s not always enough of those patients to fill the gap left by lower-paying federal reimbursements.
“So, it’s not possible in many cases without significant subsidy to operate an emergency service in a large area with small populations,” he says.
Slabach says EMS needs to be declared an essential service in much of the country so that it can receive taxpayer dollars like police or fire departments. That could stabilize many volunteer services financially and allow some or all to pay their staff. He says only 11 states have done so.
A recent Montana state health department report says declaring EMS an essential service could help. Retired Montana state health department official Jim DeTienne pushed for a bill to study the possibility during Montana’s legislative session this year.
“We’ve spent the last 50 years with EMS on the shoulders of volunteers and we need to change those things incrementally,” DeTienne says.
The bill didn’t pass, but the state health department report from earlier this year says there are other ways to stabilize volunteer EMS agencies, like merging with taxpayer-funded fire departments or critical access hospitals.
The latter is happening in the southwest Montana town of Ennis. EMS Manager and former volunteer Nick Efta says the Madison Valley Medical Center now pays staff so they can jump in an ambulance to respond in seconds. This spring, he says the service had nine calls in 24 hours.
“Given that day and how the calls played out, I think under a volunteer model, it would be difficult to make all those calls,” Efta says.
Rich Rasmussen, president and CEO of the Montana Hospital Association, says what’s happening in Ennis might not be financially viable for many of the smaller critical access hospitals that serve rural areas. Rasmussen says many that take over local EMS do so at a financial loss.
“Really what we need is a federal policy change, which would allow critical access hospitals to be reimbursed for the cost of delivering that EMS service,” he says.
Under current Medicare policy, critical access hospitals only get fully reimbursed for EMS if there’s no other ambulance service within 35 miles. A federal pilot program looking at this issue was extended earlier this year, but Rasmussen says eliminating that mileage requirement would give critical access hospitals incentive to take on EMS.
“It’s a long haul to do this, but it would dramatically improve EMS access all across this country in our most rural communities,” Rasumussen says.
But in lieu of changing state and federal policies to directly fund EMS at cost, Rasmussen and others say volunteer ambulance services will continue to struggle.
That’s impacting private paid services like Missoula EMS. Manager Don Whalen says his crews regularly respond to outlying areas 70 miles away and even across state lines in Idaho because local volunteer agencies can’t respond.
“We shouldn’t, but we know if we’re not going, nobody is coming for the patient because a lot of times we’re the last resort,” Whalen says.
Whalen says Missoula EMS has made agreements with a couple of smaller volunteer EMS agencies to staff an ambulance in the community during the day when volunteers have difficulty leaving work to respond to calls. Whalen says those agreements on top of responding to other towns where 911 calls are going unanswered is taking away resources from Missoula.
“What I’ve been trying to push with the state- I mean, we’re willing to do that, but we need some funding to help support an ambulance or paramedic out in some of those areas,” he says.
But that financial support or other policy changes that could stabilize volunteer agencies aren’t likely to happen anytime soon.
Back at the Dutton Ambulance Barn, Colleen Campbell says it’s a personal struggle for her to stay on as a volunteer EMT as she tries to spend more time with her grandkids that live out of town.
“I was thinking of not recertifying the last two times. I recertified in March of 2020, so my license is good until March of 2022 and we’ll just see. Then again, there’s only four of us,” Campbell says.
If she leaves, Campbell says there may not be anyone to replace her and that’s one less person to save the lives of her family, friends and neighbors.