A legislative interim committee began work this week in Pierre to evaluate critical challenges facing the state's emergency medical services.
The group is looking into limited ambulance availability in rural areas, staffing shortages, funding sustainability, streamlining resources and operations and other issues.
"We all know that EMS is a lifeline, especially in our rural state and how separated that we are," said the committee co-chair Sen. Tim Reed, R-Brookings, during an opening statement. "But that system we've been talking about, it's under a real strain."
Key testimony from EMS personnel and industry leaders throughout the day outlined how emergency medical services in South Dakota, and across the nation, are severely underfunded and struggling with staffing shortages. In recent years, these issues have forced organizations like the Rural Meade Ambulance Service in Enning and Bison Ambulance Service in Bison to temporarily shut their doors. Meanwhile, other ambulance services like in Isabel and Dupree are shut down.
"EMS as a whole in the United States is on the brink of collapse," said Sherry Hocking in an interview with SDPB. Hocking is the director of the Newell Ambulance Service and an EMT basic who has worked in EMS for 27 years.
"The funding model isn't there to support it," Hocking said. "People aren't paid. The pay is poor for the things that we do, getting called out in the middle of the night, seeing things you can't unsee. And people are aging out of it."
Low insurance reimbursement rates leave EMS critically underfunded
According to Brian Hambek, executive director of the Spearfish Emergency Ambulance Service and president of the South Dakota Ambulance Association, inadequate insurance reimbursement rates are a key piece of the issue. During his testimony, Hambek cited data from a cost analysis report called the Medicare Ground Ambulance Data Collection System.
"So half of the EMS agencies nationwide reported. The first year's results came in early this year. And it shows that Medicare is underfunding EMS by 55 percent. They're paying 55 percent of what it cost us to turn tires," said Hambek.
Hambek said about 64 percent of the calls that Spearfish Emergency Ambulance Service responds to are Medicare-age patients. About 17 percent are patients covered by private insurance and 9 percent are Medicaid patients.
"Medicare seems to be the biggest payer in the country. This is a nationwide for EMS. Any idea what percentage of their budget goes to EMS? Any thought?" Hambek asked committee members during the meeting. "Point-five percent goes to EMS."
In South Dakota, Medicaid recently increased its ambulance reimbursement rates to match 90 percent of Medicare. This is about 48 percent of what it costs for an ambulance to go on a call. Prior to that, the Medicaid reimbursement rates were $190 for a Basic Life Support call and $240 for an Advanced Life Support call.
Private insurances often do not pay much higher than Medicare, and Hambek says that some have barely raised their rates in years.
"Premiums go up every year, but our reimbursement has not. Which is a travesty. Flat out," said Hambek in an interview with SDPB. "And if you think of COVID happening, the cost of supplies. A box of gloves used to cost me eight dollars. When COVID hit, it was $24 bucks. So my costs tripled in some cases on supplies."
Making EMS an essential service in South Dakota
Another major topic of focus for the interim committee is designating EMS as an essential service in the state.
"If we expect emergency medical services to be there when people need them, regardless of where they live, we have to be willing to have a conversation about how we recognize, support and potentially restructure EMS as an essential part of our public safety system, just like law enforcement or fire services," said Sen. Reed.
During the last legislative session, Rep. Eric Emery, D-Rosebud, who is on the interim committee and a paramedic, introduced House Bill 1043 as a step toward supporting EMS as an essential service. The act would have created a state EMS fund and required counties and municipalities to provide emergency medical services within their jurisdictions. The House Appropriations Committee rejected the bill.
If emergency medical services are designated as essential, it generally means the state needs to provide access to those services for its citizens. However, the state has flexibility in how it organizes, supports and finances EMS and what minimum requirements it establishes across the state.
Maynard Konechne, executive director of the South Dakota Emergency Medical Services Association and a presenter at the meeting, outlined how the gap between EMS and police and fire is an issue that goes beyond state borders.
"The funding from national every year, police get $400 million in grants, fire departments get $380 million," said Konechne. "Last year, EMS on the national level got $20 million. We're trying to get $33 [million] this year, and we're not sure we'll get the $20 [million]. It's really heart wrenching to see that, the way the disparity is between EMS, fire and police."
Future solutions
While there's no "silver bullet approach to funding EMS" statewide according to a presentation by the Department of Health during the meeting, one of the options discussed is to look to national legislation that's been introduced.
For example, the TIP, or Treatment In Place Act, facilitates insurance companies to pay a base fee for patients who are treated in place and refuse transport during an ambulance call. Currently, ambulance services are rarely reimbursed for non-transport patients.
"We are doing a lot of treatment in place," said Hambek. "Now, South Dakota Medicaid is actually starting to pay for some of those if they are a Medicaid patient, which I applaud. That's great. What we need is federal to do that. And that TIP Act is in Congress, and it's been there for a while. That needs to be passed and help us out on this."
In terms of workforce shortages, a few of the solutions brought up in the meeting were promoting the EMS profession, funding for training courses from the state, efforts to improve EMS leadership turnover, enabling nurses to fill in on a call and more.
"They [nurses] do not want to jeopardize their current status as nurses just to help out. Therefore, clarification in the law and a clear statement that nurses can work in the back of an ambulance in a rural system is crucial," presented Brad Derschan, a member of the Lemmon EMT Association, in a document submitted to the committee.
The Emergency Medical Services Interim has two remaining meetings on July 23 and Sept. 15. During those meetings, the committee will discuss potential legislation to draft.
"Our scope is broad, but our timeline is not," said Sen. Reed. "We only have three meetings and so we're going to have to get focused quickly."
