Ambulance companies rethink business plan as volumes, revenue decline

Ambulance companies rely on growth in volume of reimbursable transports to cover expenses and even turn a profit.

But since the COVID-19 pandemic struck in March 2020, Michigan companies have been facing more severe staffing shortages, they have seen volume decline by as much as 40% as people choose not to call 911 to avoid potential coronavirus exposure at hospitals and inter-facility transfers have slowed.

Across Michigan, ambulance companies' and EMS responders' revenue fell, but their expenses didn't.

Last year, 13 ambulance providers went out of business or merged with another company, according to the Michigan Department of Health and Human Services. Six providers closed and five merged with other operators. Closures were in the counties of Saginaw, Cheboygan, Kalkaska, Delta and Alger.

Even before the pandemic, the nation's 911 system was strained. In Michigan, 911 calls are answered by a patchwork of nonprofit, for-profit, hospital-affiliated, fire department and municipal-run services. Michigan has about 800 licensed life-support agencies but only 300 that transport patients. The other 500 are medical first responders or basic life support agencies.

"Most likely the closures were first responders. The majority happened in northern Michigan. The pandemic has exposed even more the reimbursement and staffing issues we face," said Angela Madden, executive director of the Michigan Association of Ambulance Services in Lansing.

Kolby Miller, CEO of Medstar Ambulance in Clinton Township, said consolidation in the ambulance industry has been going on for several years and the COVID-19 pandemic will hasten the trend. Medstar is owned by Ascension Michigan, Henry Ford Health System and McLaren Healthcare Corp.

"You get to a point where ambulance organizations, whether they're public or private, the revenue doesn't keep up with the demand for wages and benefits. And eventually it becomes insurmountable. And organizations just close when you can't meet your paychecks," Miller said.

Traditionally, ambulance companies were owned by funeral homes, fire or police departments or government-affiliated. Later, private companies, including hospitals and for-profit companies, began operating ambulance services.

For example, Medstar is a nonprofit owned by hospitals and Emergent also is a 501c(3) organization owned by six local community ambulance providers. Last year, Beaumont sold its ambulance company to Superior Air-Ground Ambulance Service of Michigan Inc.

Over the past decade, private equity firms have acquired ambulance companies. Three private companies have taken over nearly 70% of the market, including Kohlberg Kravis Roberts & Co., the largest, and portfolio company Enhanced Equity.

While ambulances respond to all types of 911 calls, they are often only reimbursed when they transport people to the hospital. During the pandemic, calls for medical help in many areas of the state have surged, but those resulting in transport to hospitals have fallen.

Larger ambulance companies like Medstar, which employs 800 healthcare workers, will continue to grow as smaller companies seek to survive by sharing expenses and through economies of scale, Miller said.

"The model also allows for stability in both the 911 delivery and the inter-hospital delivery because it consolidates the geography of volume, and then we can improve service by sharing resources," Miller said.

Another problem affecting all ambulance providers is the shortage of paramedics and emergency medical technicians. During the pandemic, fewer emergency personnel have been trained and replacements have been insufficient to keep up with demand.

"We are an accredited paramedic training institution. We were doing our part, but the number of education programs have diminished, so the access to training that people might need for EMT and paramedic has diminished," Miller said.

Emergent Health Partners in Ann Arbor, one of the state's largest EMS providers with six affiliate ambulance companies and 849 employees, is another emergency provider hit hard by multiple factors all connected with the COVID-19 pandemic, but also by longstanding reimbursement and staffing issues.

With volume down and expenses up, Marc Breckenridge, a paramedic and manager of government and media relations with Emergent, said 2020 was a very difficult financial year. Revenue dropped to $72.2 million in 2020 from $73.9 million in 2019. However, Emergent's 2020 revenue was boosted by federal COVID-19 relief funds, paycheck protection and Medicare advance payments of $2.65 million.

"With COVID, our call volumes dropped 40% and we are not transferring other patients for other care as much," Breckenridge said. "Probably the biggest reason is that patients in a facility like a nursing home are urged to stay there in order to mitigate disease spread."

Breckenridge said fewer people are calling 911 for help when they need it.

"They are waiting until the last minute," he said. "By then, it's sometimes much too late to help."

Miller said Medstar has been challenged by making sure its ambulance staff has enough personal protective equipment to do their jobs and at the same time trying to ensure stress doesn't affect the mental well-being of the workforce.

During the second surge last fall, Miller said 35 Medstar employees were either diagnosed with COVID-19 or exhibiting symptoms.

"As a large EMS 911 provider, not only do we care for the patients with COVID, and the difficulties in providing that care, but we're also the ones who have to tell the family members that they can't come to the hospital, or they're not going to be able to see their family member for some time, and then manage the impact of that interaction on the patient's home," Miller said. "The care is more complicated. The support of the patient and family members is more personally taxing."

Miller said the impact on field personnel "is just crushing. I've been in this business for 37 years, as a paramedic and as an administrator, and I have never dealt with the challenges of balancing the demands and the pressures on our organization the way we are right now."

Breckenridge said Emergent's on-call times have increased by 15% because COVID-19 precautions have greatly extended the decontamination process of ambulances and staff.

"We have to be extra careful. (The time) was higher closer to the beginning of the pandemic, but has been gradually improving with experience," Breckenridge said. "We don't get paid for decontamination."

As expenses have increased for equipment, supplies and staff overtime, Breckenridge said the company has adapted to the new normal.

"We have been able to recover pretty well (this year)," he said. "We did tap into some of our reserves to make it through."

But the ambulance executives say they need reimbursement increases from Medicaid and Medicare to survive in the future.

Nationally, ambulance companies are asking states and the federal government for more financial relief. The American Ambulance Association recently asked the U.S. Department of Health and Human Services for $2.6 billion in emergency funding.

Madden said the Michigan Association of Ambulance Services and the Michigan Association of Fire Chiefs are asking the state Legislature for $5 million to boost training programs and $10 million annually to increase EMS salaries and purchase equipment upgrades.

"We haven't had a Medicaid increase in 21 years. If the state increases funding $10 million, that plus the federal match will bring rates up to Medicare, which is still lower than costs, but will help us quite a bit," said Madden, adding that legislators are considering the requests.

Michigan EMS reimbursement rates average about $178 per life support transport for Medicaid patients, an amount 50% below costs, Miller said.

"Medicare pays about 10% less than our operating costs (accounting for about half of patient volume)," Miller said. "The commercial payers pay quite a bit more. Blue Cross (Michigan) has been quite supportive. They're a little ahead of our operating costs and Medicare. Medicaid is an increasing part of our business but only pays about 25% of our operating costs."

While ambulances respond to all types of 911 calls, they are often only reimbursed when they transport people to the hospital. During the pandemic, calls for medical help in many areas of the state have surged, but those resulting in transport to hospitals have fallen.

As hospitals become overwhelmed, many ambulance services have been told to treat patients in place whenever possible and transport only the most acute cases to protect hospital capacity.

Medstar and Emergent have participated in a number of community paramedicine and mobile integrated health programs supported by the state, ambulance companies and healthcare systems to reduce trips to ERs.

The paramedicine programs allow specially trained paramedics to residential homes or facilities to assist people who may be at risk of a medical emergency. They also allow paramedics to respond to low-priority 911 calls with the goal of reducing ER visits.

Begun last year, a five-year federal payment program through Medicare called ET3, or the Emergency Triage, Treat, and Transport program, will pay ambulance providers to transport a patient to a primary care office, urgent care clinic or community mental health center for treatment or evaluation. The program also allows telemedicine visits.

"Before, if we didn't transport a patient to the emergency department, we received no compensation," Breckenridge said. "This is a small step, but we hope it will grow in time" to be a revenue source.

So far, Emergent has conducted 73 telemedicine "treat in place" visits in Washtenaw County (26) and Jackson County (47) and 10 transports to alternative destinations in Washtenaw County (2) and Jackson County (8).

Emergent also is beginning to work with some local health departments to deliver COVID-19 vaccinations to homebound elderly and also participating in a mass vaccination clinic at the University of Michigan, Breckenridge said.

Medstar also answers home visit calls through the state's mobile health paramedic program.

"Our mobile health paramedics go into those PACE (Program of All-Inclusive Care for the Elderly) participant homes and manage their care trying to avoid the ER," said Miller, adding Medstar recently contracted with Bingham Farms-based United Physicians, one of Southeast Michigan's largest physician organizations.

"We do UP's after hour patient visits in Macomb and Wayne counties to avoid ER utilization," Miller said. "We are working (to finalize) another initiative with a big (unnamed) insurance company to do more of the same."

Medstar also has a team of paramedics who do congregate care, nursing home and adult foster care center COVID-19 testing in Macomb County.

Looking to the future, Emergent is hoping to come up with a new business model that combines traditional transportation and first responder services with community paramedicine and ET3, Breckenridge said.

"We are trying to project what the future post-COVID world is going to look like. There's so many changes that have been made because of COVID," he said. "We hope community paramedicine is made permanent and increases in reimbursement will help form our future existence. The big question is what pathway the future holds."

Medstar's business model will be similar, said Miller. The company will diversify revenue sources and conduct more home visits on homebound patients who are at risk for visits to hospital emergency departments, he said.

"When people talk about being on the front line, we're in people's living rooms, it doesn't get any more frontline than that," Miller said.