CRANBERRY TWP — Of all the businesses to see a direct and negative impact due to COVID-19, ambulance services may not be the most expected. But for local EMS agencies, the pandemic exacerbated an already precarious situation.

While calls are closer to pre-COVID levels now than at the beginning of the pandemic, that does not mean all is well in the world of ambulances.

Jay Grinnell, Harmony EMS president, said his service will end the year with about 1,100 fewer ambulance trips than it provided in 2019, equivalent to a substantial drop in revenue despite no correlated drop in expenses.

“We still had the same number of employees, the same number of mortgage payments, electric payments,” Grinnell said.

In fact, COVID-19 put a strain on expenses, too. Patients are masked during transport, Grinnell said, and the cost of a mask spiked up to as much as 10 times the cost of pre-pandemic prices.

A precarious spot

While the number of ambulance trips have picked up, Grinnell said, “even if trips get back to normal, the funding is so far behind where it needs to be.”

Ambulance services are fee-for-service companies. They charge patients and insurance companies for the costs associated with the transportation. But Ted Fessides, Cranberry Township EMS chief, said the reimbursement rates from Medicare and Medicaid don't allow the service to break even.

“We have these contractual amounts that we have to accept whenever you take Medicare or Medicaid money,” Fessides said. “The government dictates what they're going to pay you. We might bill you $1,000, but if you're a Medicaid patient and it was a BLS (basic life support) transport, I'm getting paid $226.18.

“You can't go after the patient (for the balance), but we have this 24/7/365 cost of readiness. We have rent to pay, we have insurance to pay, we have trucks to buy. The last truck we bought was $187,000, and that's before you put one piece of equipment on it.”

Grinnell said most private insurance companies base their reimbursements on government rates. He described these rates as being at least 15 years out of date despite the rising cost of ambulance expenses.

The private insurers are where the relatively controversial practice of “balance billing” comes into play. Fessides said the service has, in the past, made up for any deficits caused by Medicare and Medicaid rates through its commercial insurance customers, billing them for the difference between its charges and what insurance paid.

Cranberry EMS is not an in-network provider for any commercial insurance, Fessides said, because the in-network reimbursement rates are too low to allow the service to stay in business.

A bill recently passed by Congress puts an end to “surprise” medical billing for a great deal of providers — but not by ground ambulance services. Both Fessides and Grinnell said such a provision stopping ground ambulance services from balance billing would be the death knell for a large number of such companies.

“We're not bringing in enough money to pay the bills now, let alone if we couldn't go after the balance,” Grinnell said. “That would have been a fatal blow to EMS.”

It's a far from perfect system. And Fessides said while they have been able to work within the system in the past, such a time may be over.

“Ultimately, they need to find a better funding system because the current one doesn't work and it hasn't for some time,” he said.

COVID challenges

Toward the beginning of the pandemic, COVID-19 was impacting EMS in a similar manner to how it harmed hospitals. With fewer patients and transports, ambulance services were facing larger-than-usual financial pitfalls.

That applied to both nonprofits — like Cranberry and Harmony EMS — as well as for-profit companies like Butler Ambulance.

Relief packages from the federal government, while they have aided other companies, and from the state, while helping public services such as fire departments, have largely ignored ambulance services, Fessides said.

“The priorities are still not fixed; they're shifted. That still continues to be an issue, because they're aimed in the wrong direction,” he said. “Fires have been going down since the '70s due to building codes and fire protection. EMS has been going through the roof, because that's what people do, we get old and get sick.”

Grinnell said emergency medical services should receive more attention, at the very least in terms of finances, due to the face-to-face nature with which employees greet COVID-19.

“I see a whole lot of attention being given to everybody but EMS, and EMS, at least to me, is the front line of this whole thing,” he said. “We're transporting COVID patients every day, and our employees are being put in the position where they're in the back of an enclosed ambulance for a half-hour or 45 minutes with a positive patient, and they're going home to their families after.”

Beyond the toll on the services, situations like that have strained employees, too.

“I see more and more paramedics just wanting to get out of EMS,” Grinnell said.

Grinnell said the COVID-related finance challenge has come at a rough time for the service, as it is due for large capital expenditures.

“At Harmony, we are financially surviving OK but we are going to be crushed here with the need to replace two ambulances and five heart monitors,” he said.

The ambulances will likely cost between $150,000 and $180,000 apiece, and the monitors will be in the $35,000 to $40,000 range. On the low end, that's a nearly $500,000 expense. And despite the recently passed COVID-19 relief package from the federal government, help is not on the way for Harmony or others.

“What relief is in there for EMS? And the answer is 'none,'” Fessides said. “Just like the one before that and the one before that.”

Finances aren't the end of it, either.

“We're in the top tier to get vaccinated,” Fessides said. “We have no idea where those shots are coming from or when.”

Grants and vaccines won't be the savior of ambulance services, both directors said.

“It was challenging times before this,” Grinnell said. COVID-19 has only made the situation more precarious.