How many emergency medical service providers are there in Minnesota?

As of March 2004, there are about 10,800 EMT-Basics (emergency medical technicians), about 300 EMT-Intermediates, and about 2,000 paramedics. There are 311 ambulance services. There are about 16,000 first responders not involved with transit.

As of Feb 2006

Elected officials, whether state legislators or township officers, are often expected to know everything about every issue that might possibly come before them. It is tough enough to keep track of major public policy issues, taxes, land use, etc., without being expected to know everything there is to know about matters such as the provision of ambulance service. Fire and law enforcement tend to be pretty straightforward, however, the ambulance delivery system in Minnesota is not. The purpose of this article is to offer a broad overview of ambulance services from who provides it, to who pays for it.
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General Information
Ambulance service is often thought of as one of the three major components of the public safety network along with fire and law enforcement. In reality, ambulance or emergency medical services (EMS), is a unique entity that tends to defy easy categorization. EMS is all about providing medical care, thus, it would probably fit more appropriately under the rubric of public health. This is true even if an ambulance service is provided by a fire or police department.

There are both emergency and non-emergency ambulance services in Minnesota. However, for our purposes, we will focus primarily on emergency providers. Virtually all are dispatched through the 911 telephone system and respond to any request for care. State law mandates that all emergency patients are treated regardless of ability to pay or source of payment.

The state has approximately 300 licensed ambulance services. They operate on a license issued by a state agency – the Minnesota Emergency Medical Services Regulatory Board or EMSRB. This board is appointed by the governor, with approval of the Senate. An executive director is hired by the board and serves in the unclassified service.

Included in the membership are 4 ex-officio members: A state senator and representative and the commissioners of public safety and health (or their designee). The EMSRB is an independent agency that regulates not only ambulance services, but personnel, training institutions and virtually all other aspects of the delivery system. Ours is one of only 3 or 4 truly independent EMS regulatory authorities in the country.

Emergency ambulance services do not compete. As part of each service’s stateissued license, there is a specific geographic territory in which they are the sole provider and must respond to all emergency calls. In return for this exclusivity, emergency services must treat and/or transport every patient within their licensed territory regardless of a patient’s ability to pay or source of that payment.

Ownership of ambulances is not exclusively within the purview of government. Below is a breakdown of ownership in Minnesota:

These numbers represent ownership of licenses, but some governmental entities contract with private entities to provide service. Also, the “for profit” category tends to be small, so-called ‘ma & pa’ operations, which rarely see a ‘profit’. Last, there is multiple ownership in some cases, thus the total above does not reach the 300 number, stated above.

Workforce & Training
There are roughly 6,983 individuals on ambulance rosters throughout the state. 66% are male; 59% are volunteer; 25% are paid, full-time; and 16% are part-time paid. There is some overlap, thus the numbers do not add up to 100%. The age of personnel ranges from 18 to over 70.

The people of Minnesota are heavily dependent on volunteers to staff their ambulance services, particularly outside of the urban centers. Volunteers save the healthcare system in this state just under $40 million per year.

Personnel are not “ambulance drivers”. They are well-trained and dedicated individuals who indeed drive ambulance, but they are primarily healthcare providers. From a statewide perspective, the most common level of training is Emergency Medical Technician-Basic (EMT-B). They receive over 120 hours of initial training; carry automatic heart defibrillators; Epinephrine pens; and, in many cases administer intravenous fluids.

There is another category that is very similar to EMT-B and that is EMT Intermediate. These individuals have the same basic training, but also have additional training in the use of IVs. There are very few EMT-Is because most EMT-B personnel have the additional training. Last, there is the EMT-Paramedic. Medic’s training hours varies, but the content of that training is consistent. Generally, initial training exceeds 1,000 hours. All of these personnel must take continuing education classes to maintain their certification.

One last category of emergency personnel is the First Responder. These individuals obtain about 60 hours of training. They are not formally regulated by the state. They tend to be the first personnel on the scene of an accident or medical emergency. Many parts of rural Minnesota have a true crisis in recruiting and retaining volunteer personnel. In such cases, First Responders who have met state requirements
may work on an ambulance, but only with a variance granted by the EMSRB. Regardless of whether ambulance personnel are paid or volunteer, they must complete the same training and follow the same statutory requirements.

System Funding
Virtually all ambulance services in Minnesota charge for their services. Reimbursement comes from a variety of third-party payers. Medicare is the largest single source of revenue for ambulance services, representing approximately 38% of the total. Private insurance, HMOs, automobile insurance, Worker’s Compensation and Medicaid make up the vast majority of the remaining source of revenue. Rarely, do these payers reimburse at the amount charged. A significant number of ambulance services are
subsidized either directly or indirectly by local governmental units. Government-based services tend to be more dependent on operating subsidies.

EMS is in a near-crisis mode. Volunteer services are dangerously short of staff. One or two services a year are closing their doors. In addition, all ambulance providers are facing a financial crisis as the result of shrinking reimbursements and dramatic increases in operational costs. Ill-advised changes in Medicare reimbursement policy, enacted by Congress four years ago are seriously threatening Minnesota providers. In an effort to provide a consistent, nation-wide fee schedule for reimbursement, some states were financially harmed. Minnesota was one of the three most seriously affected states. Our reimbursements were dramatically cut. Estimates of our revenue lost approaches $30 million per year.

The ambulance industry through the efforts of the Minnesota Ambulance Association (MAA) has worked diligently with state legislators to mitigate the financial damage. A number of initiatives have been enacted. A key law was the creation of EMS Taxing Districts. However, these districts are encountering challenges in getting some local governmental units to join districts and levy to support emergency medical services to their constituents.

There are 8 Regional EMS Programs that coordinate EMS in their specific geographic areas. These organizations also support local providers by administering equipment and training grants.

Although not readily apparent, there is significant private subsidization of various aspects of the EMS system. One example would be the secondary PSAPs. PSAPs or Primary Service Answering Points receive all 911 calls. If a call is serious enough to necessitate advice from a physician or hospital, the 911 call is transferred to one of the 4 secondary PSAPs in the state. All but one of these are funded by hospitals or non-profit healthcare organizations. This critical service is provided to all ambulance providers, many of which are government-based. There is no charge to providers or patients.
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The Minnesota EMS delivery system is unique in the United States. By having operating licenses issued by the state, licensing decisions are removed from local politics. The best interest of the patients is foremost. Further, we are unusual in that there is little in the way of state or local subsidization. By contrast, many states, particularly on the East Coast, are heavily dependent on a variety of direct governmental subsidies. Our system is the envy of many other states. Despite our financial and staffing
challenges, we have enjoyed unparalleled support at the state legislature. A surprising number of our legislative initiatives have been copied and found there way into other state’s law books. The state legislature has repeatedly stepped in to try to minimize the implications of federal policy decisions that have had serious financial consequences for our providers. However, the serious consequences of financial shortfalls, shortage of volunteers and increasing costs of operating a service, will manifest in the next couple of years. We need to be aware and prepared.