Maneuvering congested roads in all types of weather hazards and traffic obstacles at all times of the day and night en route to potentially life-saving missions is a daily challenge for ambulance services.

Navigating the complicated medical environment in the ever-changing health care landscape is even more challenging.

There's the usual funding crunch that goes with expensive equipment, vehicle maintenance, labor cost and rising fuel bills.

Now add to that the affects of steep increases in health insurance deductibles, reductions in Medicare reimbursement payments from federal sequestration and the rollout of the Affordable Care Act.

Making ends meet is an increasingly difficult endeavor.

“You're probably operating on a 2 to 3 percent profitability,” said Dennis Bacher, president of Butler Ambulance Service, the largest and only private ambulance company based in Butler County. “It's a very low profit margin.”

Few know better than Bacher about the operational challenges in his industry. For more than 40 years, Bacher has been a fixture at the business his father and self-described “mentor,” Clarence, started in 1967.

The Butler-based ambulance serves the city; Brady, Butler, Center, Cherry, Clay, Clearfield, Concord, Connoquenessing, Donegal, Forward, Franklin, Oakland, Penn and Summit townships; and Connoquenessing, East Butler, Prospect and West Sunbury boroughs.

“The progression of the ambulance industry over our 47 years in business has really been tremendous,” Bacher said. “It went from one or two people in an ambulance and you really didn't get a lot of treatment.

“You were called to transport and get them to the hospital as quickly as possible and let (the hospital) take over.”

The EMS Act of 1973 changed all that.

The law mandated training requirements for ambulance personnel, such as having an emergency medical technician on every ambulance and having a minimal amount of equipment aboard.

The once standard ambulance went from transportation to health care provider.

“And it has progressively improved,” said Doug Dick, a paramedic and EMS chief for the private Superior Ambulance Service in Pine Township, Mercer County.

But those improvements have not come without significant costs.

Equipment costsThe price tag for an ambulance in 1976, Dick said, was less than $30,000. Today, it's more than $120,000.The year BAS was founded, it cost just $1,200 to equip an ambulance with the bare necessities — stretcher, oxygen, splints and first aid supplies.To outfit an ambulance now, the bill is more like $60,000, Dick said.Among the standard gear is an electrocardiogram machine, known as an EKG; a defibrillator; a continuous positive airway pressure device; intravenous supplies; intubation equipment; and a radio or wireless telephone.The Pennsylvania Department of Health mandates every ambulance must comply with state and local laws and have a specialized license to serve as an emergency transportation vehicle.BAS has 10 ambulances, 10 wheelchair vans and a paramedic response truck.The Superior fleet has seven ambulances, three wheelchair vans, one critical care vehicle and all-terrain rescue vehicles.

Labor outlayFor Butler Ambulance and Superior, and all other like services for that matter, labor costs are the No. 1 expense.Butler Ambulance Service employs about 100 full-time and part-time workers, including 45 emergency medical technicians and 30 paramedics.There are 60 employees, 46 of them being EMTs or paramedics, at Superior, which covers southeastern Mercer County, southwestern Venango County, northwestern Butler County and northeastern Lawrence County.The state requires that EMTs and paramedics are certified and receive yearly refresher training.EMT certification entails skill in cardiopulmonary resuscitation, control of bleeding and shock, care of muscular skeletal injuries, childbirth, pediatric emergencies and automatic external defibrillation.A paramedic's skill level is more advanced and includes knowledge in cardiovascular and respiratory emergencies, EKG monitoring and interpretation of cardiac rhythms, insertion of endotracheal and nasotracheal tubes, intravenous therapy and much more.Staffing and retaining a highly skilled and experienced workforce is not easy, both Bacher and Dick agree.“It's difficult work,” Bacher said. “You're out working in all environments, whether it's 10 below or 100 degrees.”And sometimes you're hopping out of bed at all times of the night to head to an emergency.However, getting rich on an ambulance crew is out of the question.At Superior, Dick said, EMTs are paid $9 or $10 and hour. Paramedics get between $11 and $15. The benefits package, which includes full medical coverage, adds an additional $5 to $6 per hour to labor costs.“EMS is one of the jobs you have to love,” Dick said.There are other hefty costs in running an ambulance, namely vehicle liability and medical malpractice insurance.And of course, there's gas for all those vehicles making all those trips. Superior's fuel bill, Dick said, runs $12,000 to $14,000 a month.“I don't think people understand what it takes to keep the lights on and the wheels turning 24 hours a day, seven days a week, 365 days a year,” he said.

Subscription sign-upsSubscriptions for memberships are a part of many ambulance companies' budgets. Still, it's a relatively small portion. For BAS, it covers 8 to 9 percent, Bacher said.An individual membership at BAS costs $30 a year. An annual family membership is $45.Subscribers for their memberships receive emergency and non-emergency ambulance transportation and wheelchair van service at limited out-of-pocket expense.For subscribers, the ambulance service will respond to calls and accept as payment whatever reimbursement their health insurance covers.Nonsubscribers are billed for the entire cost of the ambulance call.At Superior, subscriptions are $20 for a single person, $30 for a couple and $40 for a family.“Subscriptions have really dropped dramatically, due to the economy,” Dick said. “They represent maybe 5 percent of our budget.”An even smaller revenue source than subscriptions for companies comes from the Emergency Medical Services Operating Fund administered through the state Health Department.A fine attached to some motor vehicle violations goes into the fund, which may by distributed to any ambulance company in the state. The collected fine money is divvied up regionally and can only be used for specific purposes to maintain or improve the EMS system.“In the end,” Bacher conceded, “there's not a lot of money.”Dick said the last time Superior got any of that money was three years ago when it received $3,000.

Failing fundingReimbursements from private insurance companies, Medicare and Medicaid make up the lion's share of any ambulance service. For BAS and Superior, it's 90 percent or higher.But reimbursements, Dick stressed, are woefully inadequate. They cover only a portion of the cost of the ambulance call.In many townships and boroughs across Pennsylvania and the country, a majority of ambulance transport patients are on Medicare.For Superior and BAS, that aging population translates to a significant gap in revenue because Medicare, the federally-funded health insurance plan for people older than 65, doesn't fully reimburse for the cost of that trip.The problem dates back to 2006 when Medicare instituted a flat fee schedule for ambulance transports, which prevented companies from recouping their actual costs.While Superior's typical non-emergency basic life support ambulance ride costs $743, Dick said it receives just $209 in reimbursements from Medicare for moving an enrolled patient.He estimated all Medicare reimbursements to be about 44 percent of the total cost billed.“You used to be able to charge for supplies you use, the actual costs,” Bacher said. “Now, your fee has to encompass everything — your oxygen, your supplies, whatever.”Because of that set fee schedule, the reimbursement rates have generally stayed the same.“The only thing we are able to charge for on top of the flat rate is a mileage charge,” Bacher said.But as deficient as the Medicare reimbursement is, Medicaid, the health insurance program for the poor, pays less.Private insurance, Dick and Bacher concede, is better than the government-run programs, when it comes to reimbursements.Superior gets 75 to 90 percent of its true costs reimbursed from Highmark, UPMC, Aetna and other insurers, Dick said.

Rising deductiblesRecent changes in health care have only exacerbated the financial struggles of ambulance services.Bacher noted one of the biggest changes in the past several years has been higher co-pays and deductibles in insurance plans. For many, patients with private plans are responsible for $1,000, $2,000 or more in out-of-pocket costs tied to medical services.That trend has seen some patients opting to forgo ambulance trips to the emergency room or declining transportation to the hospital altogether, even in the case of an accident or fire.For an ambulance service to receive payment for an emergency call, it must take the patient to a hospital emergency room.“You may be called but you don't necessarily have a transport,” Bacher said. “If there's a call with no transport, the ambulance eats the entire cost — no reimbursement.”The spread of cell phones and other mobile devices is blamed for an increase in non-transports, Dick said.“People pass by and see an accident and call 911 even before they know someone is hurt,” he said. “Once 911 is called, we have to respond, no matter what.”However, Dick said more people are using EMS as their first line of defense and thereby avoid potential bills and co-pays.He explained that a patient will request an ambulance then receive an assessment, say for blood-sugar, blood pressure or oxygen saturation, by the crew.Once that patient is evaluated, he can refuse to follow the advice of the ambulance personnel and turn down the transport.“That's like going for a doctor's visit,” Dick said.But in this case, the ambulance, not the patient, is stuck with the bill.

Sequestration bluesAnother recent change to affect ambulance services came last year when the federal government enacted a series of automatic cuts to federal spending known as“sequestration.”The impact was immediate.“In January 2013, we lost 2 percent in Medicare reimbursement,” Dick said. “In April 2013, we lost another 3 percent.”Those recent reductions were on top of the already dismal reimbursement rates.One more uncertainty is the Affordable Care Act and how it could eventually affect ambulances.“It's pretty much wait-and-see,” Bacher said. Dick seconded that.“I don't think anyone knows,” Dick said. “The powers that be who voted on this don't know what's going to happen. How should we know?”

<B>Address: </B>921 E. Main St. Ext., Grove City<B>President:</B> Mary F. Dick<B>Employees: </B>60<B>Website:</B> www.superior-ems.com<B>Service: </B>Provide emergency and non-emergency transport<B>Mission: </B>It is our mission to provide the best quality medical care, medical transportation and pre-hospital care education to our communities at the lowest cost possible.

<B>Address: </B>106 First St., Butler<B>President:</B> Dennis Bacher<B>Employees:</B> 100<B>Website:</B> www.butlerambulance.com<B>Service: </B>Provide emergency and non-emergency transport<B>Mission: </B>Butler Ambulance Service, as an organization, will be comprised of professionals progressively working toward providing and improving a comprehensive EMS system by means of leadership, collaboration, education and customer service, in the common interest of facilitating the efficiency of rendering excellent medical care and transportation to the sick and injured.