Solutions sought for ambulance crisis

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copyright the Chronicle February 14, 2018

DERBY — Rural emergency services are facing an emergency of their own. That’s no secret to those who spend hours on dark, lonely roads helping friends and neighbors who are injured or sick.

Orleans County has long been fortunate to have many ambulance squads who are willing to take on a demanding and vital job. But the collapse of one of the major players in the northern part of the county’s emergency medical services community has brought problems most saw, but few discussed, to the surface.

More than 50 people came out Monday to talk about the difficulties providers have to deal with and consider how to build a system that will better serve the people of the area.

Members of local ambulance squads, town officials, and state representatives jammed into the meeting room in Derby’s Municipal Building Monday to begin a conversation about the best way to provide emergency medical services.

The ultimate question was whether rural communities can find a system to provide themselves with prompt quality care at a price they can afford.

In a world where ambulance crews from different towns have long been motivated by a desire to show themselves as the best in their area, one might have expected resistance to any suggestion that consolidation might be a potential answer.

The idea was raised and, surprisingly, not a single person dismissed it. It seemed the crisis facing all volunteer service providers in rural communities has become dire enough to erase petty differences.

Karen Geraghty of the Northeastern Vermont Development Association (NVDA) opened the meeting. Her organization, the town of Derby, and North Country Hospital worked together to sponsor the event.

In her opening remarks Ms. Geraghty said providing services in rural areas is expensive, especially emergency medical services where time is of the essence and crews have sometimes to travel substantial distances to reach a sick or injured person.

Not only can distance mean the difference between a good or bad outcome for a patient, but also speeding to make a call places the health and safety of responders at risk, she said.

On the financial side, she noted, “resources are constrained. We need to do a lot more for a lot less.”

Emergency medical service providers are caught up in a system where reimbursement is declining and payment rates are based on the experience of urban, not rural, communities.

Government regulation and the march of medicine mean companies have to find ways to pay for more extensive training and better equipment. At the same time it is getting harder to recruit people to serve on emergency medical crews.

Ms. Geraghty said there are two ways to look at how medical services are provided. Either providers respond geographically to those within a set of borders, or they can decide to serve the needs of a population, however one wishes to define it.

She then opened the floor for discussion.

John Morley, the administrator of Orleans Village, was first up.

“Is everyone facing the same priority regarding personnel?” he asked.

Mr. Morley wondered if the state is aware of the problem and committed to finding ways to recruit more responders.

Joel Cope, Mr. Morley’s counterpart in Brighton, said he is in the position of having to find people to staff an ambulance to serve his town.

He said he may need to find full-time people who will be in the garage waiting for calls. That, Mr. Cope said, will definitely add to the expense of providing service.

Charlie Pronto, the president of Newport Ambulance, who participated in the meeting via the telephone, said, “We are not a volunteer squad.”

Nevertheless, he said, personnel is a problem for all sorts of responders.

One of the problems, he said, is that towns expect ambulances to be staffed by volunteers.

“You see fire departments are fully funded,” he said. “They make 80 calls a year and get $300,000 from a town. The ambulance company makes 600 calls a year and gets $100,000.”

“The days of volunteerism are done even in Orleans County,” said Adam Heuslein, who heads Glover Ambulance and chairs the Vermont EMS District Two, which covers northern Orleans County and much of Essex County as well.

District Two Medical Advisor Dr. Bill Brunelli said he would like to see people in the area make a plan based on what services are needed.

“We have three services in the southern part of the area,” he said. “Do we need them and do we want to support them?”

Dr. Brunelli pointed out that a fully equipped ambulance costs about $250,000.

“If every town has its own little thing with a quarter of a million dollar ambulance or two, that’s a big cost to a little community,” he said. “If you spread out the cost, everyone’s taxes may not have to be so high.”

Dr. Brunelli said he has been medical advisor to the district for the past five years. When he started he pushed for consolidation, but found a lot of resistance to the idea and stopped talking about it, he said.

Ms. Geraghty urged the group to look at problems besetting the area’s people, including an aging population and the opioid crisis.

People should consider those issues when talking about how to best serve the region, she said.

State Representative Mike Marcotte of Coventry said he’s seen consolidation working with Newport Ambulance.

“Why are costs going up?” he asked. “Consolidation is supposed to bring costs down.”

Mr. Pronto said this is a problem all over the area. In many places costs are going up dramatically, he said.

Dr. Brunelli said he would hope to hear a mention of quality, and not only cost in a discussion of ambulances.

Mr. Marcotte said he agreed. He said he hopes to see North Country Hospital work in partnership with communities in putting together a future system.

Claudio Fort, the hospital’s CEO, said ambulances are vitally important for his institution. Newport is two hours away from the two nearest tertiary care institutions, UVM Medical Center in Burlington and Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire.

Moving patients so they can get better care ties up an ambulance for around six hours, he said.

Mr. Fort said his hospital does what it can to help, including hiring specially trained nurses to ride along with patients as well as respiratory specialists when needed.

Dr. Brunelli agreed. He said many people complain that ambulances are often unavailable due to transports.

Helicopters are often grounded in this area, he noted, but patients need to get to where they can get specialized care, he said.

“If it were my heart attack, I’d want to be transported,” Dr. Brunelli said.

  1. Perry Hunt, a member of the Derby Select Board, said he called for a transport the day before.

“No service answered five times,” he said.

“That happens all the time,” Dr. Brunelli said. “I go through the local ambulances, up to the 45th Parallel, and down to St. Johnsbury. We’re trying to get people down for treatment.”

Mr. Hunt said he doesn’t think people don’t care to volunteer.

“They’re working two or three jobs,” he said.

Others disagreed. Training requirements have become more stringent over the years.

While a person with the lowest level of certification used to have only 40 hours of training, that job new requires 120.

A paramedic must go through 2,400 hours of education and spend another 72 hours a year to keep her certification.

“You have to have people making it a career to survive,” said Mike Paradis, director of Newport Ambulance. “But the community is expecting volunteers.”

Mr. Pronto said the state has imposed regulations that increase costs to ambulance services.

“Anytime the government steps in to make things better, it makes things worse, especially in rural areas.”

After Derby Line Ambulance went under and Derby signed up with Newport Ambulance, Mr. Pronto said he thought everyone’s costs would go down.

The problem in outlying towns is they do not have enough calls to support a service, he said.

“Towns like Newport and Derby shouldn’t be asked to subsidize the smaller towns, it’s not fair,” Mr. Pronto said. “We told them they are not only going to have to pay more, but the service won’t be as fast.”

Dr. Brunelli said the problem with Newport’s model is everything is centralized. He said people should stick together and create a great plan rather than say outlying areas should pay more and more and more.

“I’m looking at it as a business, you’re looking at it as a service,” Mr. Pronto responded.

Ms. Geraghty suggested it might be time to rethink how to provide services to the whole community.

Mr. Morley suggested creating a committee to study the issues and recommend next steps. He said the hospital should be part of the discussion and pointed to the court system as a possible model.

Orleans County funds the court with a county wide tax. Perhaps, he said, there can be a similar way to let everyone pay their fair share.

Dr. Brunelli said he came from Pennsylvania where they have emergency service districts. District officials decide what services are needed.

“What I’m trying to do is get the global picture on how to provide services,” he said. That means not having a system that leaves some people waiting 45 minutes for help.

Dr. Brunelli said Orleans County has about 14 ambulances at present. Does it really need that many? he asked.

He said he understands how people might want to have every ambulance staffed with a paramedic, but he noted the cost of medications to go along with a person of that skill level is another large expense.

Dan Batsie, who heads the emergency medical services division of the state Department of Health, joked that he was going to give a talk about religion in the Middle East later that day and explain which is the true faith.

That, he said, would be a safer topic than consolidating medical services.

The decline in volunteerism is not restricted to emergency services, Mr. Batsie said. Libraries, too, have fewer volunteers.

“It’s a demographic issue,” he said.

He also warned against expecting a one-size-fits-all solution.

“In Vermont, if you’ve seen one EMS system, you’ve seen one EMS system,” he said.

Mr. Batsie also cautioned against unreasonable expectations.

“Like everything else, communities will have to make choices about emergency services,” he said. “We might say we want a Cadillac, but maybe a Ford will do.”

He said the idea of a committee is a good one. If it comes up with a solution to serve the area’s needs, the state should support it.

Mr. Batsie offered to support the planning effort with data. The state has collected the time and place of every call made in Vermont, he said.

It would be simple to draw concentric circles on a map and put pins in the places where emergency medical providers have made calls, Mr. Batsie said.

With that information the committee could see the best places to locate ambulances for the fastest response times.

While regionalizing the service may make it more efficient, it is not likely to lower costs, Mr. Batsie warned. No matter what, communities are going to have to contribute to keep the ambulances and their crews running.

“Most critical infrastructure does not pay for itself,” he pointed out.

The Northeast Kingdom has to face some facts, Mr. Batsie said. Its present business model for emergency services is unsustainable, he said.

“We have to be open to new ideas and to work together,” he said.

Mr. Batsie said he understands that most people are happy to see reorganization as long as an ambulance remains in their community.

Emergency medical responders might also worry that reorganization will mean they will lose their jobs.

Mr. Batsie said, in his experience, reorganization doesn’t usually cost jobs.

He said other states have strong county governments, but Vermont has no such tradition. At the same time policing is provided by the State Police and county sheriffs. There is no such equivalent in emergency medical services, Mr. Batsie said.

Should the committee and the region want to move in that direction, he advised those in the room to speak with legislators, because state law will have to be changed to accommodate such a plan.

“I’m sorry I don’t have a great solution,” Mr. Batsie said. “I’m here to help with system planning.”

He said the state has “no skin in the game” and can offer neutral advice.

Whatever process the group chooses should be completely transparent, Mr. Batsie advised, so people can trust the decisions that come out of it.

After an hour and a half of intense discussion, the meeting broke up. Many put their names on the list of those willing to serve on the planning committee.

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