Ambulance services are on life support across Wyoming

The historic revenue crisis facing Wyoming’s state, county and municipal governments is threatening to claim yet another casualty: universally available ambulance service.

The state-wide problem is perhaps most acute in Fremont County, where a five-year-old cost-saving plan has unraveled, leaving the nearly Vermont-sized region without a single outfit interested in providing service beyond June.

Amid an economic downturn and significant budget cuts, Fremont County Commissioners opted to privatize the county’s ambulance service in March 2016.

The cost of the county-run ambulance service had been rising, resulting in a $1.2 million budget request. The county’s assessed tax base dropped 27% that year.

So commissioners signed a five-year contract with Guardian Flight. The private enterprise not only took over the EMS service, but it did so without requiring a governmental subsidy and paid the sheriff’s office more than $200,000 per year for dispatch services and another $250,000 to rent the county’s ambulance equipment.

At the time, there was a hope that Guardian — now owned by AMR — would eventually buy the county’s equipment and the original contract would’ve been just the start of a long-term relationship.

Instead, the operation lost money from the get-go; in the 2020 fiscal year, AMR lost more than $1 million in Fremont County, according to Matt Strauss, who oversees the local operation as regional director for AMR.

When county commissioners decided to issue a request-for-proposals this year after failing to reach terms on a second agreement, AMR announced it wouldn’t bid.

“We can’t sustain that kind of loss long-term,” Strauss said.

When the deadline for the RFP ended Thursday, however, no other company had bid either. County commissioners are set to discuss next steps Tuesday.

Before the RFP closed, Fremont County Commissioner Larry Allen had hoped AMR’s successor wouldn’t need any governmental subsidy, but also acknowledged that might not be possible.

“We’re hopeful that, if we have to pay a subsidy, it’ll be minimal,” he said. “If they want something like $1.5 million, the county might as well run it ourselves.”

Long-term, Allen said, Fremont County will need to find a stable source of funding for EMS.

“We’re going to have to do something, maybe a mill levy,” he said. “Those are the conversations we’ve had with other commissioners. … If towns and cities want ambulances, they’re also going to have to help out a bit.”

Fremont County is just one Wyoming community where the future of EMS is uncertain. Its struggles with financing the service underscore an issue unfolding across the mostly rural state, where cash-strapped local governments are grasping to find a sustainable funding model to maintain a service most agree is essential. 

The issue is now reaching a “breaking point that was easily predicted,” said Andy Gienapp, the state’s top EMS official from 2010 to 2021. “We have not gone about creating a design that works for the future or, when we see it, we’re hesitant to make the changes that need to happen to really design something.”

Without that foundation, communities across the state are having hard conversations as they try to forge solutions. 

No mandate, no money 

Sweetwater County Commissioners are also struggling to craft a plan to maintain EMS service amid rising costs.

In December, commissioners told their two EMS providers they’d terminate both contacts by March, saying it was “unsustainable” to continue subsidizing them. The current county-paid subsidy, $1.2 million annually, is more than double what it was just two years ago, according to the county’s budgets.

In early March, commissioners asked the cities of Rock Springs and Green River to cover half of that $1.2 million cost. The county warned the municipalities that one of the two services, Sweetwater Medics, was just weeks away from no longer responding to EMS calls. Ultimately, the commission voted to continue funding the ambulance services until at least June, while continuing negotiating with the two cities.

Contributing to the crises facing counties like Fremont and Sweetwater is a lack of a designated tax base for ambulance service and the lack of mandate to fund those services.

Wyoming counties are allowed by state law to levy a maximum of 12 mills in property taxes for their general funds — revenue that is already stretched thin funding services that state statute explicitly obligates counties to provide. 

So, for example, when Fremont County’s assessed values dropped by about $250 million for the 2017 fiscal year, the county found itself scrambling to shore up a $2 million budget deficit. State law both limited what the county could cut and barred raising taxes just as the county’s EMS director was requesting $1.2 million in general funds.

Commissioners stressed the need to focus on meeting “statutory obligations” — services like sheriffs and prosecutors.

Ambulance service is not on that list. In fact, no entity — not municipalities, counties, hospitals nor the state of Wyoming itself — is required to provide EMS to Wyoming residents.

“As we talk today, literally everybody who runs an ambulance service could stop doing it tomorrow, and there’s nobody that could make them do it,” Gienapp said of the 62 ground ambulance services and 23 air medical groups currently operating in Wyoming under a variety of contracts.

As the funding crisis worsens, EMS leaders are pushing the Legislature to establish some legal obligation to prevent a worst-case scenario.

“The ultimate risk is that you might not have ambulances coming to take care of you, and if you do, you might have to wait hours before someone gets to you,” Strauss said. “I think that’s the concern that all of us have, because we’re all health care providers and we want to take care of people.”

A volunteer base that’s running thin

That was a very real fear for residents in Weston County when Roger Hespe, owner of Newcastle Ambulance Service, announced his plans to retire in June.

Hespe has contracted with the city of Newcastle since 2000.

The EMS business in Weston County has been good to Hespe, he said, even though his subsidy from the city hasn’t increased in a decade.

“It’s a struggle. Can it be done? You bet. I’ve been doing it,” he said. “A lot of the work falls on my shoulders. I have very few days off because I have to staff the ambulances. I work a lot of hours.”

Hespe fielded 200 ambulance calls in his first year of business. That’s now up to 700.

“We’re doing more work for less money, but I never let that get to me. I just figured out how to make it work,” he said.

Hespe said there’s ample interest from others wanting to purchase his business, and he’s confident someone will take it over.

Newcastle Ambulance Service has four full-time employees and, like many small ambulance services in the state, Hespe also relies on an ever-shrinking base of volunteers. With the costs of EMS classes and certifications rising, Hespe understands why.

“If I was a young man starting out, I wouldn’t do it, because now it costs you a few thousand dollars just to get started,” he said.

Unlike other medical services, Gienapp said, EMS in rural states was built on the backs of volunteers. This has allowed communities to ignore the true cost of ambulances for a long time.

“Back in the day, it was really easy to run an ambulance service,” Gienapp said. “You’d get two or three friends together and buy an ambulance and, overnight, your small town could have an ambulance. That works as long as you and I are available to donate the single biggest cost in operating an EMS service and that is labor.”

But as EMS has become more complex and regulated, a volunteer-based system is no longer viable — nor is it fair, EMS leaders stress.

“I’m a fully qualified paramedic and if I lived in one of these small towns and they asked if I’d be willing to volunteer and ride with their ambulance crew, my response would be ‘absolutely not’,” Gienapp said. “This is my career and it’s what I get paid to do and I know what the work entails. It takes a willingness to give up time with your family. It can lead you to miss your kid’s baseball game, ballet lesson, or leaving Christmas dinner to go out on an ambulance call.”

EMS workers are also exposed to traumatic and dangerous situations, Gienapp said.

“We have plenty of EMTs and medics, and we can make more of them,” he said. “We’ve just run out of people who are willing to do this for really crappy wages. And of all crappy wages that you could get paid, getting paid nothing is the crappiest of them all.”

Those communities in Wyoming that continue to rely on volunteers are the least sustainable in the state, said Aarron Reinert, a partner of consulting firm Safetech Solutions, which has a contract with the Wyoming Department of Health to analyze the EMS systems of various communities in the state.

The dwindling base of volunteers means that many communities are just now coming to grips with the true cost of running an ambulance service, he said.

“The vast majority of any ambulance budget is salaries, and when those salaries have been free or almost free, rural EMS communities just haven’t understood that it doesn’t just cost a few thousand dollars,” Reinert said

Paying market wages, it costs about $500,000 annually to run an ambulance 24 hours per day, Reinert said. That price tag only allows for “basic life support,” which doesn’t include paramedics, he said. To operate a full-time ambulance with advanced-life support in Wyoming would cost upwards of $1.2 million annually, he said.

Billing strain

Without volunteer labor, it’s almost impossible for ambulance services to operate without governmental support since EMS billing regulations typically only allow organizations to recoup a fraction of costs, Reinert and other EMS leaders said.

EMS organizations bill only when a patient is transported to a hospital or transferred from one hospital to another.

“You’re doing a lot of free work because of those variables,” Hespe said.

And for those bills that are issued, only private insurers cover the full price, according to Wyoming’s EMS leaders.

Medicare and Medicaid pay flat rates per ambulance call and, in areas with low call volumes, those rates typically cover less than half the cost of service, Gienapp and others said. And while the cost of providing rural EMS keeps increasing, those federal reimbursement rates are going down.

Caring for uninsured patients — such as the roughly 24,000 Wyoming residents in the “Medicaid gap” — typically results in no compensation at all.

Local solutions

While EMS leaders want legislative involvement, some communities are pursuing local solutions. While state law limits counties from taxing more than 12 mills, it also allows voters to establish separate tax districts — dubbed “rural health care districts” — that can levy two additional mills that could be used to pay for EMS service, among other things.

Some communities have established such districts.

A 2020 assessment that Reinert’s firm conducted of Johnson County’s system — one that’s funded by a health district — found the service to be “sustainable long term,” noting that more than “three-quarters of the system’s operational resources come from some form of public dollars.”

Regionalization of EMS systems, in which a group of small operations join forces and consolidate services into a larger operation, is also an important strategy for improving efficiencies that stabilize service, said Luke Sypherd, who oversees the Washakie County EMS service.

Washakie County’s system is undergoing such a regionalization process now. It’s currently one of those ill-fated volunteer models, in which Sypherd is the only full-time employee. As demand for services has outstripped the capacity of volunteers, the volunteer organization is being dissolved and the county’s northern neighbors will take over ambulance service May 1.

Washakie County has inked a three-year contract with Cody Regional Health, which is based in Park County.

This type of regionalization is effective, Sypherd said, because duplicative positions can be consolidated and there’s less idle equipment.

“You don’t have to have quite as many ambulances because, within your own system, you’re able to accommodate for what’s called surge capacity,” he said. “When you have a large incident, you have a bigger pool to pull from, including employees.”

The contract with Cody Regional Health also means Washakie County’s volunteers will have a chance to make EMS a career.

Sypherd recently hired on with the Cody business, and most of his volunteers have also been offered jobs, he said.

“Most of these volunteers have been doing this for a very long time, so they’re very professional and experienced, but they just don’t get paid,” Sypherd said. “They get stretched very thin between taking shifts, family time and their own jobs.”

Because Sypherd and his team will remain based in Washakie County, he said residents there shouldn’t see any drop-off in the level of care. If anything, he expects response times to improve because the delay of volunteers heading to the station will disappear. 

“If you can reduce time, you can reduce mortality and morbidity rates, which then, in turn, has a huge ripple effect on the economics of health,” he said. 

Legislative needs

Even with regionalization, Sypherd says the Legislature still needs to address structural problems with EMS funding.

Sypherd co-founded the Wyoming EMS Association in 2019. As the organization’s current president he’s spent much of the last two years  trying to educate legislators and Gov. Mark Gordon’s administration about reforms that will make ambulance service more reliable and stable, he said.

When Wyoming’s economy rebounds, Sypherd said, the Legislature should establish an interest-bearing “sustainability account” that provides grants to local EMS agencies.

“When we’re in a time of plenty, let’s plan for famine,” he said.

Strauss, Gienapp, Hespe and Sypherd all stressed the need for the Legislature to codify EMS as an “essential service” that’s required to be provided by local governments.

Fremont County Commissioner Allen said a rural health district could ultimately be a solution for his community. He’d welcome involvement from the Legislature, he said, but only if the end result isn’t an unfunded mandate. “I think if the Legislature would get involved, they need to involve everybody, including both the municipalities and counties to understand their needs,” Allen said.

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Reinert is less optimistic that the Legislature is the right avenue to fix EMS’s funding woes.

With options like rural health districts already available, Reinert said the onus is on communities to commit funding.

“At the end of the day, I think that emergency management services are a local problem and I think the only thing that’s sustainable long-term is a local solution,” he said. “I worry that when we create a one-size-fits-all solution, it will lead to unsustainable models in local communities.”

During Sypherd’s lobbying efforts this year, several legislators on the Labor, Health & Social Services Committee were surprised to learn that EMS isn’t deemed an essential service, he said, and he’s hopeful there will be a legislative effort in coming years to mandate it as such.

He acknowledges that a new tax proposal will receive substantial pushback, but he’s not buying arguments that the state can’t afford to subsidize EMS.

“To say we can’t afford it I think is false,” he said. “It’s that we don’t want to afford it. We don’t want to cut other things that aren’t as essential or we don’t want to pay additional money to cover it, but when residents of counties and cities call 911 and they don’t get an ambulance, or they get inferior service, they’re not going to be happy.”