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THERMOPOLIS — How do you offer quality services at an affordable and sustainable business model? That is the question facing emergency medical services around Wyoming and around the country.

To help answer those questions, the Governor’s Health Task Force and the Wyoming Department of Health have been seeking input and information about the current operations and challenges to Emergency Medical Services in Wyoming, conducting five listening sessions around the state to gain information from the stakeholders providing those services.

One such listening session, for region 5 that includes Washakie, Hot Springs, Big Horn, Park and Fremont counties was held in Thermopolis on Wednesday, June 15. There were representatives from Cody Regional Health that provides ambulance services in the Cody area, south Big Horn County and the Worland area, Mortimore Ambulance Service that is contracted by Hot Springs Health to provide ambulance service in Hot Springs County, Powell Valley Healthcare, North Big Horn Hospital and Global Medical Response.

The sessions were led by Jen Davis, health and human services policy advisor for Governor Mark, Aaron Koehler of the Wyoming Emergency Medical Services and Dirk Dijkstal of the Health Readiness and Response division.

THE ISSUES

The issues that have plagued Washakie County EMS including declining volunteers, finding funding and not being legally considered an essential service, are plaguing other services as well.

According to Dijkstal, EMS is a 24-hour-a-day, 365-days-a-year system that serves as a “critical safety net for many Wyomingites.”

In 2021, Wyoming EMS responded to approximately 89,000 requests for service. Cody Regional Health EMS Director Phillip Franklin said in Worland they average about 1,000 requests annually. Scott Murphy of North Big Horn Hospital ambulance service said they average between 600 and 650 annually.

Dijkstal said a basic system needs at least 650 calls annually to be sustainable and an advanced system needs between 1,400 to 2,000 to be sustainable.

There are 48 Wyoming based ground 911 response transporting EMS agencies in the state staffing 78 stations. Wyoming’s EMS systems, according to the Task Force presentation, are operated by hospitals, fire departments, private non-profit and for-profit corporations.

Powell, Cody and Lovell in the Big Horn Basin have hospital-run ambulance services.

Per the Task Force, funding mechanisms for EMS are fragmented and diverse and there are significant differences in service between frontier, rural and urban communities throughout the EMS system.

According to state statistics there have been 10 EMS transporting agencies that closed, three in Region 5 — Greybull Fire Department, South Big Horn County Hospital District and White Line LLC doing business as Atwood’s Family Ambulance. Those three are handled by Big Horn Rural Health District No. 1 that contracts with Cody Regional Health.

Volunteer service Washakie County EMS was one of 11 services that were replaced by another agency. Washakie County, except Ten Sleep, is now serviced by Cody Regional Health.

Dijkstal said in the past six years from 2016 to 2021, EMS requests for service overall in Wyoming have increased by 27.15%. Region 5, however, has seen an increase of 34% in total documented service requests, increasing from 5,124 in 2016 to 6,899 in 2021.

According to the Task Force data, 911 responses represent more than 70% of the service calls but about 35% of them do not pay.

Murphy and CRH EMS Quality Supervisor Luke Sypherd said there are other non-911 calls that they respond to and that the community expects them to respond to that they do not bill for including lift assists and standbys for accidents, fires, community events and sporting events.

According to the Task Force one of the biggest challenges to sustainability for EMS is funding. Dijkstal said nationally a basic life support ambulance costs $507,474 to operate annually with $70,000 in equipment and the rest in staffing.

In contrast, an advanced life support ambulance service (which is what CRH provides to Washakie County) staffing costs $1.1 million.

He noted that according to the National Fire Protection Agency, first responder agencies have experienced approximately a 27% decrease in volunteers since 1987.

Dijkstal said in a recent study by the Wyoming Ambulance Trip Reporting System, the No. 1 barrier to staffing for an EMS agency was lack of volunteers and the No. 2 reason was wages. Other issues were funding for operations, rural area, billing difficulties and competition from other agencies.

Top challenges to sustainability for EMS agencies was staffing (No. 1) and funding (No. 2). Other challenges were wages, cost of living, workload and high volume number for requests required.

STAFFING

Whether volunteers or paid staff recruitment and retention of staff was mentioned as an issue by most of the EMS agencies in attendance at Wednesday’s meeting.

It was also noted that there is an aging workforce with no replacements in sight, burnout and looking for the work-life balance.

Sypherd said rural locations for Wyoming hinder retention when people realize that they are 90 minutes or more from Costco.

Generational differences were also noted with many old EMS employees raised to give back to their communities and the newest generation looking at monetary incentives, Murphy said.

Murphy added that he loses some in the age range of 19 to 25 because it is difficult to get them insured as drivers, or the cost of the insurance is too much for the budget.

Arleen Campeau, chief nursing officer from Powell Valley Healthcare said, “Workforce is really important but you have to have money coming in in order to hire workforce. I think reimbursement is very poor. And you have a lot of self-pay patients who can’t pay, let alone with have 75% increase in fuel costs and rigs that get 6 miles to the gallon if we’re lucky. Expenses are going up but reimbursements are not.”

Becky Mills, Ten Sleep ambulance director, noted she is one of the exceptions in the room as the EMS system is a town-based volunteer system. “We have people in our community who see the need and who are stepping up and coming in and joining us. We are able to manage most of the time on our own. There are a few days of the year we have to call up Cody Regional and say “hey if we get a call it’s coming to you.”

She said one of her biggest concerns is education. “I don’t think I can ask these volunteers to drive two hours to a college and take an EMT [emergency medical technician) class. So I’ve been teaching them there in Ten Sleep. We used to get reimbursed by the state. When funding in the state office got cut so did our funding for classes. They still cover our testing.”

She said she donates time and resources to teaching the classes because it is important to have EMTs in the community.

Murphy added, “It’s been a big challenge to offer local classes. Everybody thought the move should be that we would rely on community colleges to teach us and take it away from the local level. When your guys’s funding got cut and that went away I think that is what helped accelerate our shortage of staff.”

He said they can attract people to come and take classes but when you tell them they have to go to the community college when you are working it can be cumbersome.

“I guess we were spoiled, we had that funding coming from the state for a long time to at least pay a portion of instructors,” Murphy said.

Mills added that they cover a lot of territory in the Big Horn Mountains and they know they can respond quicker than other agencies. “That’s why we are holding on, out of stubbornness.”

Murphy said another big issue is the fact that ambulance service is not considered an essential service in Wyoming, meaning the state, county or municipalities are not required to provide EMS to residents.

When asked about mental health patients, Murphy said transports tie up an ambulance for a long time. “We are covering a service no one wants to cover and we are covering it for free,” he said.

Murphy added, “An ambulance service has the worst business model. Why do that, but somebody has to so the question is who is that someone and how are you going to pay for it.”

STRENGTHS

The group on Wednesday did note some strengths with Sypherd said that services are local and housed within communities.

Community support is also a huge strength.

Sypherd and Franklin said communities in south Big Horn County have overwhelmingly supported mill levies for the Big Horn Rural Health District to fund the parademic ambulance service provided by Cody Regional.

In a recent survey in Washakie County there was 84% of respondents in favor of a quarter of a cent sales tax to pay for Washakie County ground and air ambulance services. The tax question is likely to come before voters in November.

Sypherd said another strength is the employees who are invested in help people and who live in the community. “We have a community-minded workforce, which transfers to exceptional quality care.”

Powell Valley Healthcare emergency medical service and emergency room manager Scott Bagnell said community support is also big in Powell. Bagnell and Murphy said community members were concerned when word got out that ambulances are not considered essential services.

He also said their employees are always willing to work to help other employees and cover shifts.

Bagnell said another strength is the cooperation among emergency agencies within specific communities such as fire and law enforcement, but also with other emergency medical service agencies in the Big Horn Basin.

He said they all work together to help fill in when one agency is too busy.

“This is not really a one area or one town problem. I think the communities need to come together, ambulance services across each region and then work to bring all the agencies across the state together in order to make a big change like this,” Bagnell said.

EXPECTATIONS

The task force also wanted to know what community expectations were for EMS agencies and the overwhelming response was quality service and availability.

Campeau said they have a fair share of calls of people who have fallen and can’t get up. “There’s not a lot of services to help with those situations.”

As the Wyoming Department of Health had to cut home health services, those services have fallen to EMS agencies.

Campeau added, “We’re happy to do that but there is a cost that is not being reimbursed. If EMS is going to be part of the home health care solution they need to be paid for it.”

Murphy said, “They want the best care they can get and they want treatment to start right away, which is at least ALS level and paramedic level.”

North Big Horn Hospital CEO Eric Connell said that providing a high level of care will attract people to the area, but if it is not offered, they will consider other areas to live.

Washakie County Emergency Management Director Kami Neighbors said another factor is response to remote areas with residents and visitors coming to the Big Horn Basin for its outdoor recreation opportunities.

She said residents understand the logistics of EMS responding to a call in the mountains but “I don’t know if visitors realize that.”

Murphy added that the area due to weather and wind can provide no-fly days so a transport that would normally be a flight transport goes by ground.

“Last week we had five transfers with two pending because flights could not come in. You do the best you can,” Murphy said.

Sypherd said communities also expect the standbys for fire calls, community events, derbies, rodeos. “There is an expectation from public and private organizations and we have to schedule staff for those,” he said.

He said calls also typically surge in the summer but EMS agencies can’t hire seasonally because of the training required.

SOLUTIONS

The Wyoming Legislature, through Senate Enrolled Act 20, appropriated federal American Rescue Plan Act (ARPA) dollars for various purposes including $87,000 for establishing emergency medical dispatch statewide certification; $5 million for grants to stabilize emergency medical services and $10 million for EMS regionalization pilot for the five trauma regions, in order to investigate alternative options for EMS to improve access and reduce cost, according to Dijkstal.

One solution on retention mentioned Wednesday was retention bonuses instead of or in addition to signing bonuses and bonuses for increasing education so you keep employees longer as they are paid to train.

Murphy said assessments for EMS agencies would help answer some of the questions, exactly what do the communities expect and what will they support.

All were in agreement that EMS agencies need to be considered essential services, which would open other funding sources.

Other suggestions were:

•Using a portion of the lodging tax to help pay for services since visitors use the services.

•There needs to be a change in the 35-mile rule. According to the Center for Medicare Services benefit policy manual, “The fee schedule applies to all ambulance services, including volunteer, municipal, private, independent, and institutional providers, i.e., hospitals, skilled nursing facilities and home health agencies covered under Medicare Part B, except for services furnished by certain critical access hospitals (CAH). Payment for ambulance items and services furnished by a CAH, or by an entity that is owned and operated by a CAH, is based on reasonable cost if the CAH or entity is the only provider or supplier of ambulance services that is located within a 35- mile drive of such CAH. The provision is effective for ambulance services furnished on or after December 21, 2000.”

In Wyoming, most ambulances do respond beyond a 35-mile radius from the hospital.

•Bolster education opportunities and funding so agencies can “grow” their own employees rather than having to recruit from other states.

•Improve billing to get proper reimbursement from insurance and Medicare and Medicaid. Some agencies said the billing and ambulance coordinate to ensure things are coded properly for billing, others said they do not have the staff.

The agency representatives said they do not expect the state or federal government to just come in and fix it. Murphy said, “We’re going to have to fix ourselves but we need a push to get over the hump and it’s going to take some funding.”

Dijkstal said one idea that came from the Casper meeting was to allow county commissioners to establish districts, much like solid waste districts. The districts would have to be approved by the voters.

NEXT STEP

Davis said there is one more meeting, this will be a statewide virtual meeting at 11 a.m. on Tuesday, June 28.

“Encourage your legislators, mayors and commissioners to log in. We need that whole collective voice,” she said.

People can join with Google Meet at meet.google.com/moq-bxeu-kon.

Following that meeting she said Dijkstal’s team will take all of the information and analyze it, look for things unique to each district and compile a report looking at where the state goes for the next step.

She said the information will be brought back to the communities.

“There are tough conversations ahead and we are just starting to dig in,” Davis said.

The meeting began with recorded remarks from Wyoming Governor Mark Gordon. “We recognize the challenges facing our emergency response efforts across the state, However, I believe we are on the right path towards finding sustainable solutions to this critical issue. I want to emphasize that I am committed to working with all of you to find solutions to these challenges. By working together we can develop a strategy to accomplish our goal of stabilizing Wyoming’s EMS services. These services are the lifeline of our communities. A healthy, stable and sustainable EMS system is critical to ensuring Wyoming has a high performance health care system,” he said.