What Higher EMS Pay Requires

I know that the debate on EMS wages did not begin last week with Sean Eddy’s post “5 Reasons Why EMS Doesn’t Deserve Higher Pay.” For instance, Caitlyn Armistead did a great article last October entitled “Burger Flippers Vs. Ambulance Drivers” long before her recent rebuttal in “5 Reasons EMS DOES Deserve Higher Pay“. The extremes of passions also came out in another post at this site that has helped propel the debate if even in a less than civil manner. Catherine Counts also recently added her voice, and unique perspective in the “EMS Pay Debate.” Recently, EMS World also ran an article written by Gary Ludwig. In addition, there has also been a mixture of passions and reasoning on many Facebook pages and I am sure several other places I haven’t even discovered yet. The common thread between most of these is that they focused on who we are as the health care providers in the field. While I am a relative newcomer on the ambulance, the vast majority of my career has been in consulting on business process improvement and I would like to share what I have discovered in my journey to a job in EMS.

What Higher EMS Pay Requires

While I wholeheartedly agree with improving our educational requirements, it is not because of any direct causal relationship between scholastic degrees and financial compensation within our field. After all, the core design of the EMS industry is based on provider certifications rather than personal knowledge. By definition, we provide circumscribed care to the sick and injured based on protocols and guidelines, not based solely on our own intuition, beliefs, or even “ninja-like” skills. The services we work for are reimbursed for the production of “transportation units,” not compassionate care. The fundamental truth we must recognize is that our agencies have historically been paid for the number of patients delivered to a hospital. Period. Even though most field providers are concerned about “doing the right thing” for our patients; we are simply not compensated, at least in any large measure, for the level of “care” we deliver. Diagnostic technology has advanced, training has improved, even our knowledge of human pathophysiology has grown tremendously. But the financial model that drives our employers is fundamentally unchanged from the days when funeral homes scooped the dead and dying off the streets. The Centers for Medicare & Medicaid Services (CMS) and insurance agencies simply “reimburse” agencies based on formulas of care. Quality beyond basic competence, at least prior to the Affordable Care Act (ACA), has not been a criteria.

Our skilled care, compassion, and like it or not; our response times, rhythm analysis times, 12 lead performance rate, mileage reports, patient satisfaction scores and all of the other graphs posted on the bulletin board at your base are important in allowing our employers to keep a contract. It doesn’t matter fundamentally whether you are employed in a local government “3rd service”, private contractor, volunteer service, or whatever. Your employer has a “contract” to provide services that can be lost and replaced with another service model. This contract, often as a sole provider, eliminates significant competition at the patient level. They have an emergency, they call 9-1-1 and accept the level of care provided while en route to the hospital for that occurrence. If cumulative expectations are not met by the public, a change in the service is demanded. This arrangement far from absolves us of personal responsibility for the quality of service, but should actually drive us to improve in all measures (especially those that impact the continuity of our employment.) EMS Compass is a new initiative to help map out the measurement of performance in EMS services. If we care about the future of our agencies and the conditions we will work under, we should become actively engaged in this program. But it doesn’t end here. The whole employee/employer relationship must be born of a mutual respect and understanding.

To say that “corporations make huge profits and can therefore afford to pay living wages” or “our work is so risky to our personal mental health that we deserve more” are not only simplistic ideas, but they set up an adversarial relationship with employers in place of a cooperative one. We must work together throughout all levels of the organization to show value (or need) in order to justify the allocation of additional funds for whatever purpose.

Similarly, we must also refrain from dividing ourselves from each other. I have heard several complaints that volunteerism in EMS holds wages down. This is a spurious argument in my opinion for two basic facts. First, in many areas, a lack of volunteer EMS services would simply mean a lack in any professional prehospital emergency services there. In rural areas where population density is low, demand is also typically low along with the financial resources to sustain a paid service. Extreme rural lifestyles have a different balance of costs and benefits that cannot be compared with extreme urban choices. It is unfair (and burdensome) to demand equality of services in either case – even if it were possible to achieve. Law enforcement and fire protection services are also routinely provided differently at either end of that spectrum and accepted as a part of the lifestyle in that area. Secondly, wages are only a portion of employer expenses. For any “business” to succeed (and yes, you work for a “business” if only in a broad sense of the term) you need to constrain debits (operating expenses) relative to credits (budget allocations, fees or other reimbursements.) In some cases, services can operate at a deficit if they are recognized as providing an intangible service greater than their expense. Reedy Creek Fire and Rescue, for instance, provides all services to the visitors of Walt Disney World at no charge because Disney sees a value that outweighs the cost and is consequently willing to pick up the entire tab. The majority of the world, however, must show “tangible values” that exceed their costs of operation in order to collect any fees from whatever payers. The fact that a volunteer is willing to drop everything at a moment’s notice to attend to the injury of another human being has never taken food from the mouth of an EMT somewhere else. We may not all be equal, but we are the same nonetheless.

If the intention of increasing educational requirements and eliminating volunteers is to reduce the available workforce in order to improve competition for positions and by extension improve our wages, then it will be a failure. If we raise the knowledge level of providers and therefore allow them to perform different roles such as Community Paramedicine (or Mobile Integrated Healthcare if you prefer), then we have a basis for providing new value. The next step is to find someone who is willing to pay the costs to support that improved value. This is where the ACA has brought quality of care into the picture. If a patient requires re-admittance to the hospital for the same condition too quickly, the costs that the hospital has incurred in the treatment of that patient will not be reimbursed. We currently operate at the gateway to that readmission process and potentially stand to save hospitals significant sums of reimbursement payments if we can form successful financial partnerships that ensure proper care at the lowest cost. We already work in the home environment and should have the necessary skills to ensure that a high quality of care is maintained through the “convalescence” period following a hospital discharge as well as transport critical patients for treatment. We need to accept, however, that we are not simply “public safety” agents, but agents of “healthcare reform.” This alignment can pit us against aspects of the nursing field, but we can be relevant here as we are a significant, educated local workforce that already possesses the unique skills and patient familiarity required to perform the job.

Attempts to address our personal pay by reducing workforce potential (by setting higher educational standards for providers or eliminating volunteers) is actually counterproductive because it forces agencies to streamline the production process actually making working conditions worse. We are better off expanding our scope of practice and providing extended value to patients and other health care partners. We cannot blame wages on the workforce just as we cannot presume our employers are greedy bastards. This infighting and misplaced aggression only confuses the issue. The agency compensation model must change by altering the basic business paradigm in order to see meaningful change in wages. Further, choice must be introduced in patient endpoints for service as well as seeking compensation for services based on the provision of a “level of care” as defined by medical outcomes or patient satisfaction.

Mobile Integrated Healthcare is our greatest promise for changing the model. In many cases, laws (and even service charters) must be changed to allow the field of paramedicine to grow. The Field EMS Bill is attempting to make basic changes and is our best hope in that regard. Making ourselves better providers may make patients, or our employers, happy by providing better “9oth percentile statistics,” but that in itself doesn’t change the underlying business model to generate the revenues required to pay employees more.

We need to mimic nursing professionals, or even doctors, as our political role models; not compare ourselves to fast food service workers. Each of us must become politically engaged in the changes that are being discussed within our industry and work to affect change that is in our best collective interest. Communicate and project professionalism to the community we serve in order to gain their respect and elicit their support as a valuable partner in the health care of our community. We must work cooperatively to seek new opportunities to increase and provide economic value. Seek creative partnerships that tap new revenue sources instead of increasing the competition for diminishing grant opportunities. Wages will change when we decide to work for them.

11 Comments

  • Nancy Magee says:

    Thank you, hallelujah and AMEN. Unfortunately The echo chamber of social media will continue to rant, rave and blame because it is easier and more fun than accepting facts. Nice job laying out the facts.

  • Tami Bulik says:

    Could not agree more with you! I especially like your reference to becoming politically engaged and advocating~~90% of the loud mouths on social media probably can’t tell you who their local representatives or congressmen/women are or what bills are in their state legislature that will affect their industry….

  • Mike says:

    I think equating increased education with a subsequent decrease in providers is not the mechanism that will change the business model.

    What education permits is to give a standardized measure by which policy makers can identify and justify changing the reimbursement scheme. If you consider: Doctors have an advanced education. NPs, advanced education, PA, CRNA, all the way down the line. They have basically used their education to demonstrate they are “white collar” workers who should be paid for their increased knowledge and decision making ability. (collectively, there is always that “one” provider)

    EMS however is focused on “blue collar” skills, as was pointed out in the article. A provider could have a PhD, but if they continue to leverage skills instead of knowledge, in a measurable form (recognized degree level), policy makers are not going to have the tools they need to justify higher spending.

  • ANDY says:

    If you want to increase the wages form and join a union it is the only thing that has ever raised wages for a large group of people with interchangeable skills.

    • Kim says:

      I have worked for companies that were union and companies that were non union. The pay is always the same. I have been in EMS for 24 years and I have never earned a living wage. I always have to have multiple jobs just to get by. No vacations, no credit cards and no car payments. I live on the bare minimum. I currently have 4 jobs. My EMS job pays me $13.08 per hour. My rent is $1350 per month, and that’s a good deal where I live.

  • Kim says:

    “Wages will change when we decide to work for them.” I don’t know about you but I have been busting my butt for 24 years for better wages. I continually educate myself to gain knowledge beyond my scope. My scope of practice limits what I’m allowed to do but it doesn’t limit what I am allowed to learn.

    To see my co-workers and I work as hard as we do and be as professional as we are and have you say, “Wages will change when we decide to work for them.” It is VERY offensive. Maybe YOU’RE not working for better wages but many of us are working for them, and have been for many years, and we still see no improvement.

    When you say, “Wages will change when we decide to work for them.” Please speak for yourself and don’t use the word “we”. You don’t speak for me.

    • daleloberger says:

      Thank you for making the comment, Kim. I suspect you may have missed my meaning in that statement though. The passionate folks in EMS are some of the hardest working people I know. My complaint is certainly not that “we” don’t put enough into our jobs to deserve better pay, it is that we must do more than simply do our jobs. We (the entire community of EMS) need to work to build a profession from what is currently paid only as a vocation. We must lobby legislators and the public to help them understand our value in the community and even extend that value through changes to our operating guidelines and scope of practice. It is one thing to do a great job at our jobs, but if we want to make something more of them in order that “we” don’t have to work multiple jobs in order to make ends meet, we need to go beyond the physical and mental job requirements and do what it takes to become recognized professionals. No matter how long we wait or even how loud we complain, no one else is going to promote our unique value the way we can do it. What I suggest in that statement is not that we simply work harder, but that we need to go beyond the current industry definition of what our job entails. As long as our agencies are reimbursed only for the distance we transport patients, we cannot expect wages beyond those paid to employees who are graded by the number of burgers they process. Real wages are based on perceived value. It will take a different kind of work to change that equation.

  • Steven Lichtenberg says:

    The biggest issue in pay scales is one you hit on directly. Payment for service rendered is solely based on transports. Refusals/DNR/DOA etc are not reimbursed. Once Medicare determines that we are in fact medical professionals and not “ambulance drivers” and pays for care rendered we have a chance. Community paramedicine is one mechanism for that. Statistics are just now starting to bear out what we have known empirically for a while. Providing care to patients in the home does in fact improve outcomes and reduces hospital admissions. Being paid for the care of patients through this model and for service rendered to include care in an acute situation over and above the transport will have to happen prior to increases in pay for our profession. The Field EMS Bill will certainly help and everyone should be writing your representatives in Congress in support of this bill. Consistent standards for providers across the country and a demonstrated decrease in overall per patient spending will encourage these changes. Once that happens, pay will increase similarly to other health care providers pay.

  • This article is spot on – the rapidly changing healthcare finance environment is a game changer for us – IF, and ONLY IF, we can prove that we bring value to the payer… Does our care make a difference in the patient’s experience of care, outcome and cost of care… By assessing our patient satisfaction, demonstrating improvement in meaningful patient outcomes, and reducing the cost of care, our value – and the rate people pay us – can dramatically increase…..

  • Luke says:

    How about the company you work for makes 800 on one call and you make 600$ after two weeks of work…. And running 50 calls… Let’s just be a little more fucking fair here….

  • John McCarty says:

    good article – hadn’t realized there was a Field EMS bill to support, will look and find it. I am at the far end of my career as a Paramedic and have seen great improvement in wages, even though they are not what they should be. I will continue to support our move to professional provider status.

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