The Cost of Care

Enterprise & Features

Emergency aid to rural houses difficult, costly Ambulance services hurting

PARIS, Ark. — When an emergency call comes into the Logan County Emergency Medical Services station in Paris, response can be complicated by obscure directions and uncharted country lanes.

On a recent call, paramedic Machelle Jay headed to the garage to make sure one of the station’s two ambulances was ready to roll out, while emergency medical technician Jordan Wilson looked for the address on a map of the county that hangs on a station wall.

“GPS has made this easier,” Jay said from the passenger seat of the ambulance as Wilson drove to the address. Even with GPS, though, finding residences in the 732-square-mile county often comes down to cell-phone conversations with the patient’s family while the ambulance is en route.

An hour later, Jay said that non-emergency calls such as this one — transporting an obese elderly patient complaining of nausea and diarrhea to a hospital — have become common. Often, the family has no other way to transport a relative to the hospital.

“Most people would not call an ambulance because they’re suffering from diarrhea and nausea,” Jay says. “Lately, it would be very typical. Routine, even.”

The non-emergency call is what rural ambulance services in Logan and other Northwest Arkansas counties are facing — serving an aging, rural population with limited resources.

The county has four advanced life-support ambulances — the other two are stationed in Booneville — and the travel time to a rural address can tie up an ambulance crew for more than an hour, Jay said.

BUDGET CUTS

A full-time paramedic in Logan County earns $30,600 a year, while an emergency medical technician earns $26,400. Wage freezes have been in effect for full-time county employees since 2009, and countywide, 18 percent budget cuts in 2010 resulted in a 2013 budget of $973,542 for Logan County emergency medical service, according to the circuit clerk’s office.

Betty Fairbanks, Logan County EMS director, said the cuts made it difficult to make full use of the county’s four ambulances. The service has nine full-time paramedics and three emergency-medical technicians between its two stations.

“It is running us ragged,” Fairbanks said. “We have the trucks, we just don’t have the funds for the personnel to keep the trucks running all the time.”

The U.S. Census estimates that in 2012, people 65 or older made up 17.6 percent of Logan County’s approximately 22,000 residents. Fairbanks said that the elderly made up the vast majority of passengers for the service, which answered more than 2,600 calls in 2012.

“We are an elderly county — probably 75 percent of our income comes from Medicare and other secondary sources,” Fairbanks said. “As our population gets older, they tend to become our patients.”

The rural nature of Logan County often requires both time and effort to locate emergency callers, as well as longer transports once a patient is aboard. Neither of the county’s two hospitals have the resources to provide specialty medical services. As a result, Logan County crews often must transport patients to hospitals in Fort Smith, Little Rock or other cities, tying up ambulances for as long as six hours on a single call.


“Twenty or 30 years ago, we went to Little Rock once or twice a month,” said Fairbanks. “Now we’re going two or three times a week.”

TRAUMA CARE

Logan County EMS is primarily funded through the billing of Medicare, Medicaid or private insurance. Transport base rates range from $300 to $600 plus a charge of $11 for each mile the patient is transported to a medical center.

The service also received a grant of more than $23,000 in 2013 from the Arkansas Department of Health for upgrading equipment and procedures to meet guidelines for the Arkansas Trauma System, implemented in 2009.

Statewide, the program has provided more than $13 million in grants to hospitals and emergency services during fiscal 2013. Joe Martin, trauma program manager for the state Health Department, said the program has helped to bring medical care in Arkansas more in line with national standards.

“It’s certainly improved emergency care in the state,” Martin said. “[In 2009], the state had no designated trauma centers — none. Arkansas was one of only three states in that category.”

Today, there are about 70 designated trauma centers throughout the state. Thirty-nine of them, including both of Logan County’s hospitals, are Level 4 centers, which meet the minimum requirements for inclusion in the program.

The Health Department lists five Level 1 hospitals in the state network, although three of them are outside of state in Memphis or Missouri. Another two, Arkansas Children’s Hospital and University of Arkansas for Medical Sciences, are in Little Rock.

Most severe trauma patients in Northwest Arkansas are flown to St. John’s Regional Health Center in Springfield, Mo. Northwest Arkansas has no Level 1 trauma centers, although Washington Regional Medical Center in Fayetteville is designated as a Level 2 trauma center.

Other counties throughout Northwest Arkansas and the state employ a mixture of public and private ambulances to cover their jurisdictions.

In three of the area’s most remote, neighboring counties — Boone, Newton and Searcy — ground ambulance services are coordinated through North Arkansas Regional Hospital in Harrison.

Brian Unruh, director of the hospital’s emergency medical services, said the hospital’s fleet of 13 ambulances answer about 7,000 emergency service calls a year throughout the three counties.

Unruh said about twothirds of the calls require advanced life support practices, which trigger the hospital’s highest base-rate charge for ambulance services — $650, plus $15 per mile of patient transport. Unruh said that even at those rates, operational costs limit profits for the not-forprofit hospital.

JUMP IN FEES

Rural ambulance services in the state’s more affluent areas aren’t necessarily having an easier time.

Kara Funk, chairman of the board of directors for Northeast Benton County Fire and Emergency Medical Services, uses one word to describe the district’s ambulance budget: “Shoestring.”

The emergency services district was formed in 1985, when what was then the Volunteer Ambulance Service collected $15 annually from each rural household in the district. In 2007, voters approved an increase to $40 per household per year.

In 2010, Northeast Benton County Fire Department absorbed the volunteer ambulance service, bringing the area’s rural firefighters and two ambulances under one roof.

After six years of budgeting operations off the $40 emergency medical services district fee, Funk and her fellow administrators are pushing for a 150 percent increase in annual fees, raising membership to v$100 per household.

“It’s only a large percentage increase because of the numbers we’re dealing with,” Funk said. “If we

were going from $350 a year to $450 a year, that’d be one thing. But when you start at $40, any real amount you increase is going to look large.”

Funk stressed that the service, which has a handful of full-time paid employees and volunteers, is straining under its budget limitations.

“We’ve made a lot of sacrifices over the years. None of our employees receive any benefits — no hospitalization, no 401(k) matching, nothing. They’ve stuck with it because they wanted to see the program go from a basic life-support system to an advanced life-support system, and it has,” Funk said. “But we have no reserves. We have no city council to go to, no general fund. We don’t have deep pockets — what we have is what we’ve got.”

A July 9 special election will determine whether the residents of Benton County will be willing to fund the services to the degree Northeast Benton County Fire and Emergency Medical Services administrators are requesting. In the meantime, the rural department continues to play a part in a larger mish-mash of ambulance services that serve the rural residents of Benton County, which is itself under increasing pressure from its municipalities to reimburse them for their help in serving rural areas.

In 2009, city administrators began requesting reimbursement from the county for ambulance calls to locations in unincorporated areas of Benton County. The ensuing process of assessing what the county fairly owed the providers, which include seven municipalities and Northeast Benton County, has resurfaced at the county’s Quorum Court repeatedly over the last few years.

“For as long as there’s been ambulance service in this county, the city providers have furnished the service into the county,”said Benton County Judge Robert Clinard. “They did it at no charge to the county, and recouped their costs from insurance or private payments, but the county didn’t reimburse them.”

NO LINE IN SAND

In 2012, ambulance agencies from the county’s eight providers answered 2,181 calls for service in unincorporated areas, providing 1,649 patient transports, according to data from the Benton County Department of Emergency Management. Municipal administrators complained that although they were charging individual patients for transport, they were still running a deficit. None of the seven municipalities receive any of the $40 emergency medical district fee paid to Northeast Benton County, which answered 372 of 2012’s rural calls.

Bentonville Mayor Bob McCaslin, who said he began lobbying Clinard’s predecessor, David Bisbee, for reimbursements in 2009, said he was only asking for what’s fair.

“We didn’t draw a line in the sand,” McCaslin said. “We just said, ‘Here’s the service we provide, and we ask for your consideration.’”

Clinard and the Benton County Quorum Court agreed to appropriate funds for reimbursing the cities, and earmarked $100,000 in the county’s 2011 budget for ambulance service payments. In 2012, the county raised the amount to $150,000, and again in 2013 to $300,000. But Clinard said city administrators complained to him that the amount simply wasn’t enough.

In January, Clinard asked city administrators to provide him with figures they felt would adequately reimburse their respective services. Cumulatively, the municipalities asked for about $1.1 million a year, with some areas calculating that each ambulance call cost their city nearly $1,000. At that point, the Benton County Quorum Court had what Clinard described as “a conniption.”

Clinard said that with only a few exceptions, he believes the county can agree to a fair payment schedule within the year, using a sliding reimbursement scale based in part on the number of rural ambulance calls each municipality typically answers throughout a year.

“One-size-fits-all isn’t going to happen,” Clinard said. “Every provider has 10 different factors — different area, different terrain, different equipment. To say that they all have to be the same is fantasy land.”

Clinard said there were still details to be worked out, and that the needs of the county’s rural residents is a complex question, requiring more than a quick fix.

“That’s a pretty long answer,” Clinard said.

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Originally published June 20, 2013 in the Arkansas Democrat-Gazette

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