I know that the debate on EMS wages did not begin last week with Sean Eddy’s post “5 Reasons Why EMS Doesnâ€™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 ofÂ 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 theseÂ is that theyÂ 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 â€œ9oth percentile statistics,â€ 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.