About 30 times a month, patients come to the emergency room at Rush Memorial Hospital and end up waiting — and waiting, and waiting — sometimes up to 20 hours.
That’s because those patients require medical treatment that the hospital, located in the small, rural town of Rushville, can’t provide, and need an ambulance transport to a larger facility that offers higher levels of care.
Rushville is a small community about 50 miles southeast of Indiana with a population of about 6,000 people.
The problem is that more often than not, there’s no qualified paramedic available to do the transfer. That leaves the hospital scrambling to convince out-of-town ambulance services to drive sometimes up to an hour to come and pick up their patients for transport.
Carrie Tressler, the hospital’s vice president of nursing who oversees its emergency services, said they’ve been trying to hire a paramedic for two years to do the ambulance transfers, but they’ve not had one person apply for the job.
“We’ve been fighting that battle of figuring out how to get our patients to higher levels of care without a paramedic,” she said. “But we’re kind of in a pickle. When we say, ‘Hey, come to our facility and do transfers in a rural community,’ that’s not appealing to paramedics.”
Rush Memorial Hospital isn’t alone. Across the state, the number of paramedics and emergency physicians in rural communities is rapidly shrinking, leaving emergency medical services scrambling to fully staff their ambulances for 911 calls or hospital transfers.
And it’s in rural areas where paramedics are needed the most.
State EMS Director Kraig Kinney said ambulances in rural parts of the state have to drive further to reach a hospital, and that means patients require more intensive care for longer periods inside an ambulance. Paramedics are the only ones qualified to perform more complex procedures such as inserting IV lines, administering drugs and applying pacemakers.
“Those rural areas are the places that really need the paramedics, but it’s a challenge to come up with enough,” Kinney said.
In fact, some counties in southern Indiana don’t have any paramedics, according to Sara Brown, an EMS representative on both the national and state board of the American College of Emergency Physicians.
Brown also practices emergency medicine for Parkview Health in six rural counties, including Wabash, Huntington, Noble and LaGrange counties. She estimated that region alone needs up to 20 more paramedics or other emergency personnel to be fully staffed.
Statewide, Kinney estimated Indiana needs around 1,000 more paramedics to fully service rural areas, as well as some low-income urban areas.
The problem is only set to get worse, according to the “National Study of the Emergency Physician Workforce, 2020.” The study says of the 48,835 clinically active emergency physicians in the U.S, just 8% are practicing in rural communities. That’s down from 10% in 2008.
So how did Indiana end up with a rapidly evaporating pool of paramedics serving rural parts of the state? Like many issues, the problem boils down mostly to money.
‘THERE ARE NO PROFITS’
State EMS Director Kinney said funding EMS services is complicated, but at its core, the reason there are fewer paramedics in rural areas is simple: They don’t make enough money.
He said on average, paramedics working in smaller communities or in rural counties earn on average between $35,000 to $45,000. But head to an EMS service in a larger city, and paramedics could pull in salaries as high as $70,000.
Parkview’s Brown said her rural EMS service not only can’t compete with emergency providers in larger cities — they can hardly compete with salaries paid at some retail stores or fastfood restaurants.
“Absolutely, the pay is low,” she said. “It’s a huge issue. We see people leaving the EMS workforce to go to factory jobs or Walmart or even to flip hamburgers, because they either make the equivalent or, in some cases, more in those jobs.”
Kinney said the problem is that for most rural EMS providers, they simply can’t afford to pay paramedics well because they barely bring in enough money to stay open. And the main reason for that comes down to how ambulance services are reimbursed by insurance.
Right now, insurance is only required to reimburse EMS services if they actually transport a patient to a hospital. That means if paramedics arrive on scene, treat the patient at home, but don’t actually take them to a medical facility, they don’t get paid.
“We do treatments. We use medications. We make them better,” Kinney said. “Then we talk to a doctor and they say they don’t need to come in. Right now, it’s very challenging to get paid for those runs.”
State EMS Medical Director Michael Kaufmann said on average, EMS agencies perform more than 10,000 runs each year where a patient refuses transport to the hospital, leaving the provider to eat the cost of the trip.