INDIANAPOLIS – Emergency Medical Services in Indiana often rely on volunteers and don’t have dedicated funding streams to pay for training or ambulances – but those efforts may not be enough to sustain the industry anymore.
In 2018, 4,900 paramedics and 14,000 emergency medical technicians (EMTs) responded to approximately 750,000 ambulance runs. By 2021, the state lost 300 paramedics and 1,000 EMTs but the run volume increased by 66% to more than 1.25 million, state data shows.
In that time, Indiana also lost 200 ambulances and several emergency providers closed following years of lagging reimbursements.
The problem became apparent to the Governor’s Public Health Commission in March, when Stephen Cox – the former director of the Indiana Department of Homeland Security – provided information to members.
“We often talk about EMS being the frontline to the healthcare system,” Cox said. “EMS is in trouble nationwide for a couple of different reasons. One of them is funding. However, one of the biggest problems… is that call volume is going up.”
Michael Kaufmann, the former chief medical director for Indiana Emergency Medical Services, told the committee that the types of runs hadn’t changed but calls for ambulances to 911 increased in all areas.
Kaufmann left the agency in April while Cox left the agency in June.
Cox and Kaufmann told committee members that some ambulance providers over the years have closed, partially due to staffing pressures but also because Indiana’s Medicaid reimbursement for ambulance services lags.
“If we go back to how our EMS started 50 years ago, it really started as a way to move our patients very quickly from the scene of an accident to a hospital,” Kaufmann said. “It has evolved dramatically. We’re doing basic procedures, cardiac monitoring, medications, intravenous therapies but because of the humble beginnings of EMS, EMS is reimbursed as a transportation mechanism… it’s not based on the amount of care administered.”
Spurred by their presentation, the committee dedicated one of their five public health recommendations to the state’s EMS system, highlighting the need to expand and sustain Indiana’s EMS workforce.
In a draft of recommendations, the committee suggests conducting an assessment of the specific EMS needs across the state, looking at funding and recruitment in underserved areas of the state, establishing long-term retention plans and expanding community training and paramedicine programs.
The committee voted in June to approve recommendations but didn’t finalize wording or suggest a funding amount.
Former Sen. Luke Kenley, a co-chair of the committee, said the committee would recommend establishing a fund for EMS training and vehicles – two core shortages – on top of the $250 million investment into the public health system. Counties could potentially apply for a matching grant to establish training providers and buy vehicles.
“It’s a pretty big budget request,” Kenley said. “I’m hoping that with all of the (incentives) we’re going to hold out there… that (county leaders and legislators) think, ‘We’ve got to get in on this program.’”
The struggle to train, attract EMTs
Similar to other states, Indiana’s EMS system varies from county to county and each entity – whether county or city, private or volunteer – operates relatively independently from one another.
Kraig Kinney (From the Indiana Department of Homeland Security)
“We see the biggest difference in the rural areas because the urban areas tend to be more metropolitan and predominantly fire-based (EMS),” Kraig Kinney, the state director and counsel of EMS said. “Whereas in the rural areas, those are a lot more county-based where you have one county provider for a very large geographic area.”
Where rural areas struggle the most is providing the standardized training required for EMTs and paramedics. EMT training can take five to six months or 380 hours while paramedics need over 1,000 hours and can need schooling for up to two years.
When Kinney trained as an EMT in 1991, he drove from Putnam County to Indianapolis twice a week for classes and twice a week for clinical training and again in 1994 when he trained as a paramedic. Now classes, but not clinical training, can be virtual but many areas still don’t have the resources or certified institutions.
Once trained, convincing employees to stay despite higher rates of PTSD, substance abuse, divorce and burnout becomes another challenge. With wages averaging $15 per hour, many find opportunities elsewhere.
“You’re seeing people who – 30 years ago – would stay for a 30-year career. (Now) they’re leaving after three or four years because they’re thinking… they’d rather go get a factory job that they’re going to make more money at and not have all the risk (and) mental health issues,” Cox said. “A lot of young folks are saying, ‘I don’t know if I want to go through all of that.’”
Cox, a former paramedic with a fire department in South Bend, said that while labor shortages affect many employment sectors, emergency services have an even greater problem.
“COVID was positive for EMS in terms of us meeting community challenges,” Kinney said. “But it was very risky for EMS, very tiresome and we saw some burnout and we have not recovered from that.”
The state also doesn’t track whether licensed EMTs or paramedics use their licenses, meaning someone licensed as a paramedic like Kinney, who works on administration and training but not in an ambulance, counts toward the state’s numbers.
“If you ask (EMS professionals), they’ll say, ‘I love this job but I’m overworked. I just can’t support my family on this,’” Kinney said, meaning many choose between staying in the industry or having a family.
The impact on Indiana’s trauma care system
Indiana is one of 11 states that defines EMS as an essential public service but neither funding nor the level of readiness for EMS is specified, meaning coverage varies between wealthy and impoverished communities. The state offers some limited grants but nearly all funding is local.
EMS plays a central role in Indiana’s trauma care system, with trauma the leading cause of death for Hoosiers under the age of 45. Though a majority of Hoosiers, 92%, live within 45 minutes of a trauma care system, large portions of the state don’t have coverage, including along high-traffic corridors along interstates.
Additionally, all four of the state’s Level 1 trauma centers, a designation that means the hospital can respond to any type of emergency medical care, are located in Marion County.
In Indiana’s urban or suburban counties, more ambulances and hospitals mean that response times are lower and patients can receive care within minutes. In rural counties, it can take hours.
Stephen Cox (From the Indiana Department of Homeland Security)
“If you go to a rural county like Crawford County, I believe there isn’t a hospital in that county, much less multiple EMS resources,” Cox said. “If I’m correct, Crawford County only has two full-time ambulances in the county and if they transfer someone to the hospital they have to go out of the county.
“That takes the resource out of the county. You can imagine, then, how that might impact (another) patient who calls 911 to get to a hospital, especially if they’re in critical condition.”
The General Assembly passed a bill increasing reimbursement rates under Medicaid that went into effect on July 1 as well as a bill redefining ambulance services. But those bills come too late for the EMS providers that closed and for the EMTS or paramedics who left the industry.
For Kinney, the stress of the job is worth it.
“We all care about people at one level or another. You’re out there and you are able to care, to help,” he said. “Frankly, we’re not saving lives every run… but what we’re doing is we are easing suffering. We are reassuring people and we’re preventing conditions from worsening… (and) make a difference.”