An Interview With Maine's EMS Director on Service Shortages
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It’s a challenge that we’re working to address—to sustain these smaller communities and maintain their service levels—but that is something that nationally in states that have rural areas, we’re all trying to figure out how to make it work.
Sam Hurley, The State of Maine’s Director of Emergency Medical Services (EMS)
We always think that if we are ever in a situation in which we need to call 911, whether there’s an intruder in the house or a family member is collapsed or unresponsive, that there is an operator waiting, ready to dispatch an ambulance to zoom to the rescue.
However, there’s no guarantee that when you call that an ambulance will show up to help you. Emergency medical services (EMS) are not considered essential in 39 states.
“In all the other states, there is no requirement that that jurisdiction provide EMS services. So, theoretically, no one could come,” Sam Hurley, the state EMS director of Maine said. “You expect to call 911 and get a firefighter or a police officer. The same expectation is there for EMS.”
Local governments have been in charge of organizing the structures and funding of their local EMS services since the horse and buggy days. Depending on where you lived, the first response service may have been run through the local hospital, the mortician, or if you were outside a city, it may not have existed at all.
The situation is not that different today. Your area’s emergency response service may be run by a private agency, the local fire department, or the local hospital. It may be funded by a combination of different sources, such as Medicaid and Medicare reimbursements, federal grants, income or sales taxes, and even community fundraisers, charities, and crowdfunding.
Many jurisdictions also rely on volunteer emergency medical technicians (EMTs) to keep the costs of running these services low.
The patchwork model has worked well in cities, where there is high, consistent demand for EMS. But in recent years, some EMS agencies—especially those in rural areas—have begun to tear at the seams.
“Nationally, as people continue to gravitate toward population centers, it’s becoming tougher to maintain [the current model],” Hurley said. “The clinicians we have in our rural communities volunteer their time because these communities are so small that their agency probably doesn’t run enough call to support having a paid ambulance service so there are volunteers in these ambulances.”
Meet the Expert: Sam Hurley, Maine’s EMS Director
Sam Hurley started volunteering as an EMT as a 16-year-old high school student, attracted to the idea of being able to help people in their hour of need. While his time as an EMT made him fall in love with healthcare, he quickly became frustrated with the role.
“I saw that there was more that I could do in the field of EMS and I couldn’t do it [with just the EMT certification],” he said.
Hurley started getting paid work in EMS during college, after securing his paramedic certification. At the age of 19, he was one of the youngest paramedics in the state.
Paramedics are also first responders, but have a higher educational level. In addition to the scope of practice as an EMT, they can also administer medications, resuscitate patients and start IV lines.
Hurley went on to gain a master’s degree in public health from the Emory University in Atlanta and his executive master’s in emergency and disaster management from Georgetown University. In 2017 he became the EMS Division Chief for the D.C. Department of Health, where he stayed for two-and-a-half years, before becoming the state EMS director of Maine in 2019.
He graciously shared his perspective on the EMT shortage facing rural communities in Maine and across the nation.
The Challenges of EMS in Rural Regions
Across the country, certain pockets are experiencing hardship. Almost a quarter of Pennsylvania’s EMS agencies shut down between 2012 and 2018 due to budget and staffing shortfalls. Similar situations have arisen in New York and New Hampshire.
Areas with low populations do not work well with the for-profit business model because the cost of keeping responders on call 24 hours a day and other operational costs, like fueling and servicing ambulances.
This pressing situation has been building for some time. In the 1970s, the federal government began to expand EMS services. In 1973, Congress enacted the EMS Systems Act, which funded the training of EMTs and paramedics and created a new grant program to further the development of regional systems. More than $300 million was channeled into EMS feasibility studies, planning, operations, expansion and improvement and research.
With federal support, states created about 300 EMS regions, most of them encompassing multiple counties. This facilitated “the EMS system’s interaction with the larger healthcare and public health systems” and made states eligible for federal funding for their EMS programs.
However, in 1981 the Reagan administration signed the Omnibus Budget Reconciliation Act (OBRA) into law, which revoked that funding. In the following years, jurisdictions had to become creative about how to continue to fund these crucial services, leading to the various makeshift EMS models we have today.
Since then, EMS’s position within healthcare at large has fallen into a gray area; the healthcare sector takes the position that EMS should be a public service (like police and fire), while public groups take the position that EMS should be encompassed within healthcare.
An Exodus of EMTs?
Intertwined with the funding problem is another major issue: a shortage of EMTs. These are the first responders who answer emergency calls at all hours, perform CPR, bandage wounds, and sometimes administer medication on the way to the hospital. They are essential to EMS systems.
However, because the role is often used as a stepping stone for other medical careers, it gets little respect from the public; they are often mislabeled “ambulance drivers.”
“Colloquially, if you ask EMS clinicians, they will tell you they’re the red-headed stepchild of the healthcare system,” Hurley said. “It takes an investment of time and money not only to get the initial [EMT] education but to maintain it.”
Despite the fact that becoming a licensed EMT usually requires 120 to 150 hours of training and exposes workers to traumatizing and even hazardous situations, EMTs often make minimum wage—and in many rural areas, even volunteer their services for free. Many of these volunteers are also holding down full-time jobs and volunteer as an EMT simply because if they didn’t, nobody else would.
This is often necessary in regions with low populations, where it’s difficult for EMS agencies to break even, let alone turn a profit.
A Spotlight on Emergency Medical Services in Maine
“We [in Maine] have a lot of areas that have low population density, akin to some states in the Midwest,” Hurley said.
Maine is one of the most rural states in the country, with over 60 percent of its population living outside of urban areas. It is estimated that the state needs 15 to 20 percent more EMS workers to meet demand.
“That is something the state faces as a concern because it is somewhat more difficult to get clinicians in these rural areas. That’s something we’re trying to work on,” Hurley said.
This has been a growing problem over the last few years, but during the onset of the pandemic, some of the state’s EMS agencies were concerned about the continually dwindling availability of volunteers during the public health crisis.
“It’s a challenge that we’re working to address—to sustain these smaller communities and maintain their service levels—but that is something that nationally in states that have rural areas, we’re all trying to figure out how to make it work,” Hurley said.
Coming into the role of state EMS director with a long background as a first responder in rural and urban environments, Hurley understood the hurdles that the workers themselves face, as well as the problem that Maine is up against.
In addition to being one of the most rural states, Maine also happens to be the “oldest,” with half of the population over the age of 44. Because older adults (65 and up) are the most likely age group to need an ambulance, the state’s rural communities can’t compromise on reliable first response services.
A significant chunk of the state’s funding comes from reimbursements from Medicare and MaineCare, the state’s Medicaid-funded insurance for the poor. However, reimbursements aren’t usually enough to cover the costs.
Like other states with spread-out rural populations, local hospitals in Maine have had to close departments and curtail services, so patients often need to be transferred to emergency rooms and full-service hospitals in the larger towns, which are often a substantial distance apart. This dumps an additional financial burden on the already strained rural ambulance services.
In the past two years, two of Maine’s EMS services (County Ambulance in Ellsworth and Tri-Town Ambulance and Emergency Rescue in West Paris) have shut down due to insufficient funding.
“For Maine, we are currently preparing to embark on a strategic planning process to address a lot of these concerns,” Hurley said.
One change in the works is to help set a minimum reimbursement rate for EMS transports.
“This will make sure EMS agencies are being paid enough to cover their costs associated with those transports, to not only protect the EMS agency for sustainability purposes, but most importantly, to protect the patient,” Hurley said.
“We are in the process of trying to become more innovative and trying to expand our horizons,” he added. “How are we going to think about sustainable staffing models and volunteer agencies with our rural constituencies?”
A Revolution in EMS: Community Paramedicine
The framework of our nation’s approach to EMS could be on the verge of a transformation that would not only make EMS models more efficient but also would better serve patients—and even benefit the EMS workers themselves.
The EMS Agenda 2050, a product of the EMS Office of the National Highway Traffic Safety Administration, details a vision for the future of EMS in the U.S.
The agenda bases much of its model on community paramedicine, a concept that “embodies the idea of connecting people with healthcare without them having to go sometimes great distances to get it,” Hurley said. “It connects those clinicians with people so that the patient doesn’t have to decide between taking a day of work and being short on the paycheck and going to a doctor and getting the care they need.”
The Benefits of Community Paramedicine for Patients
Fundamentally, the model aims to increase the skills of EMS workers so that they have the ability to identify a patient’s ailment—either at the patient’s home or via phone or video call—and determine if the patient needs emergency transportation to a hospital before putting a patient in the ambulance.
“All of these conversations are bubbling up across the U.S. right now in varying stages,” Hurley said. Maine has been moving in this direction for the past few years and has already started its own community paramedicine program.
“We are evaluating pilot projects right now that have expanded scope that allow paramedics to do things that normally they would not be able to do under their traditional scope of practice,” he said.
For patients with chronic illnesses, community paramedicine could be a life-changing offering.
“For a person who has congestive heart failure that is not managing it very well, what if we are able to put a paramedic in their home to visit with them and discuss the importance of taking their diuretics with them? And be able to connect them to that resource more frequently?” Hurley said. “Think about those patients who are home-bound: that would be a dramatic change for them.”
There is also a tremendous benefit in avoiding an unnecessary ambulance ride, which can be long and costly. This could potentially alleviate enough financial pressure for EMS services to be able to serve rural communities consistently and perhaps even offer paramedicine workers better pay.
The Benefits of Community Paramedicine for EMS Professionals
Community paramedicine also presents an opportunity for future EMS workers, whose scope of practice will be widened to include more patient engagement and responsibilities. An increased level of education will likely be required beyond the EMT certification, but in return, clinicians will likely earn higher wages and have greater career opportunities.
The Future of EMS in Maine and Beyond
“Right now there is so much room within this field to grow and to make it what it needs to be to really bridge the gap between patients and the healthcare,” Hurley said. “That’s really where I see us going.”
It is still up to states’ regulatory bodies to choose whether or not they will move towards this new community paramedicine model. For some, it will mean legislative changes, but it seems that the patchwork model is at the beginning of a slow evolution toward becoming a more comprehensive system.
“It may not be that your individual town has a service anymore; it may be that your county has a service and that county provides the services for your town,” Hurley said.
For individuals that are interested in healthcare careers, it could be an incredible time to get involved in EMS, an evolving field in need of entrants.
“Being able to have a voice and impact on something that will be long withstanding is an incredible opportunity—whether you’re volunteering or you come on part-time or even full-time, at any level,” Hurley said. “All levels have a role and are essential and it’s an incredible time to be a part of the conversation.”