MILWAUKEE — The number of private ambulance companies helping answer the city’s 911 calls has dropped from three to two, putting additional pressure on an already stressed system.
The I-Team has followed the situation closely. Even before the pandemic, the private ambulance companies were dealing with a nationwide EMT shortage, stagnant reimbursement rates from Medicare and Medicaid, and an increasing 911 call volume.
Pile on the coronavirus pandemic, and the system reached a breaking point. The owners of one of the three private partners, Paratech Ambulance Service, decided it would end its agreement with the fire department to answer 911 calls in the northwest part of the city, exiting officially in October.
The two remaining private ambulance companies, Bell Ambulance and Curits Ambulance Service, were already struggling to meet the city’s standards for response times and calls handled. Taking on Paratech’s calls would not be immediately possible, meaning they would fall on the Milwaukee Fire Department.
The 911 system in Milwaukee is a tiered system between Advanced Life Support (ALS) calls and Basic Life Support (BLS) calls. The private ambulance EMTs handle BLS calls, which are typically non-life-threatening emergencies, so the MFD paramedics can focus on the more severe ALS calls.
If a private ambulance company cannot take the call, they report what’s called a “turn-back,” meaning another private ambulance company is asked to take the call. If they all turn back, the fire department has to handle the call.
MFD Chief Aaron Lipski explains that can affect the entire system, and potentially lead to longer wait times.
“If that (BLS) system is underperforming it pushes all of that work that otherwise that would occur there up into the fire department system proper,” Lipski said. “What this results in is fire engines and ladder trucks at the emergency medical runs waiting on what is categorized as a basic life transport, and if there are no basic life transport ambulances available, the only available options then are our advanced life support paramedic units.”
The city tracks those turn-backs and sets standards they expect the private companies to meet. When Paratech announced it would be leaving the agreement in May, only Bell was meeting city standards, turning back less than 3 percent of calls. Curtis was at a rate of 21 percent and Paratech was turning back 43 percent of its calls. These were the most recent rates presented to the Ambulance Service Board from September 2020 to March 2021.
With multiple issues facing the private ambulance companies, those involved all recognized a need for several solutions.
The most obvious would be hiring more EMTs, but it’s not as simple as handing out job offers. It takes time to recruit and train EMTs, and the need to cover Paratech’s calls was imminent.
To cover the next few months, the city agreed to enter a unique partnership, putting their EMTs in the private ambulances.
The fire department EMT would drive the patient ambulance, while the companies' EMT would care for the patient on the way to the hospital.
It effectively doubles the capacity the private ambulance and fire department can cover. Previously, the fire department designated two of its spare ambulances to handle the increased BLS calls.
“The second we turned that system on they were maxed out and way beyond capacity,” Lipski said. “So until the rest of the system catches up, we’re trying to do what we can to impact that overflow.”
Bell is participating with three ambulances and Curtis plans to contribute with one ambulance.
“I would say this program will run for up to six months while Bell and Curtis continue to work on increasing capacity to hopefully take over that entire area,” said Bell Ambulance Director of Operations Chris Anderson.
“The two private ambulance services that were left were put in the situation where they were losing money,” said Curtis Ambulance CEO James Baker. “And so the city really stepped up to the plate in reliving. We were a more cost-effective solution and from a time standpoint, you can’t even buy ambulances for more than a year out.”
The I-Team was invited to see the new partnership in action at the end of the inaugural shift. Adam Kuhs, the deputy director of Bell Ambulance, was on that first 24-hour shift.
“This is a historical thing that's happened, so I want to see it through,” Kuhs said.
He worked out of Engine House 36 near the intersection of 27th and Capitol, one of the busiest houses in the city for EMS calls.
It was an interesting transition, eating meals alongside firefighters and working out of a new space, but the calls were similar.
“It was as if I was working with someone who I had worked with for months,” Kuhs said.
We spent the morning in the firehouse with Bell Ambulance EMT Quinten Nation, who worked alongside MFD firefighter Jack Sides. Despite different uniforms and an ambulance with an orange and white paint job, the work seemed to be business as usual.
“It's been something new,” Nation said. “It's something that's rewarding and a great experience.”
“At the end of the day we’re all still doing the same job,” Sides said. “We're here to help people.”
We rode along to calls with MFD Assistant Chief Joshua Parish. He says this stop-gap helps the department handle long-term solutions currently in the works, which present their own challenges exacerbated by the pandemic.
“What we’re seeing is an increased demand and draw on the system from a variety of areas,” Parish said. “2020 and 2021 were incredibly trying years for emergency services and for the healthcare eco-state as a whole. This is just another one of those things in a long list of immediately available solutions to address what have become two of the most interesting years in recent human history.”
There’s a financial side to the equation as well. It was no secret the private ambulance companies lost money on the 911 calls they answered.
The calls Paratech used to handled were in areas where a large portion of patients are insured by Medicaid and Medicare.
When the private ambulance companies took those calls, they were only reimbursed a fraction of the cost. A typical cost in an ambulance is about $525. Medicare pays back $365 and Medicaid is even less, $185 a ride.
The heads of Bell and Curtis say they wanted to continue to serve the city, but it would become increasingly difficult to operate under these rates.
This summer, the Legislature approved an increase in the Medicaid rate. But it was still beneath the federal Medicare rate.
“It's still under-funding the system but it's an improvement, and it's the first improvement we've seen in years,” Baker said.
The rate increase doesn’t kick in until the start of the year. And it was not enough for Bell and Curtis to expand to take on Paratech’s call volume.
“To provide the service that the residents of the northwest side deserve, we have to invest in infrastructure, not just people, expanding our workforce, but physical buildings, locations,” Anderson said.
The private ambulance companies and MFD had to work with the city of Milwaukee for additional help.
So they proposed subsidizing the 911 calls taken by the private ambulance companies. It was approved in October shortly after Paratech’s partnership ended.
The subsidies were paid retroactively from March 1 of this year. For Curtis it is based on an increasing scale. Calls between March and October range from $41 to $47 per call. After the agreement was finalized, they were to receive $61 per call.
Bell will get $81 for every accepted call from March 1 to the end of the year. It was approved in conjunction with the partnership to put private ambulances in fire houses.
The subsidy right now is set to expire at the end of the year. The chief anticipates they will ask for an extension on the subsidies, even with the rate increase kicking in at the start of the year.
It seemed like the cheaper option. Lipski said at a point he considered taking on all BLS calls and ending the private agreement.
“The legacy costs and the material costs, the capital investment to do this, to adequate cover the city for BLS transports is on the tens of millions on an annual basis, and then multiply moving forward with any coefficient you need for inflation,” he said.
It was more than a funding issue. Those dollars would go towards hiring more EMTs to build up the private companies' capacity to handle more calls.
The pool of EMTs has been dwindling even before the pandemic-induced labor shortage, with many potential candidates lured to higher-paying jobs like on-site EMTs in hospitals or large warehouses.
“I’ve always worried about how many people are going to want to get into healthcare?” Anderson said. “But as they often do people rise to the challenge.”
The fire department has agreed to start training EMTs at the academy for the private ambulance companies, and actively works with Milwaukee Public Schools to recruit future EMTs while they’re still weighing their options for after graduation.
It presents some unique opportunities as well. EMTs trained at the academy who go on to work for the private companies, would someday be good candidates to become MFD paramedics.
It’s a similar path Chief Likpski took himself, working his way up from one of the private companies.
“We now have a known quantity of somebody who is interested in the work, and the ideal would be, and Bell and Curtis would have zero issue with this as long as we’re not vacuuming up their entire employee population,” Lipski said. "It’s a very normal thing to come through the private ambulance system and try to get on a fire department. I did it.”
Not only grow that pool long term, but also diversify the EMT force in the city of Milwaukee. A small step in an even bigger challenge of promoting “medical literacy” among the residents of the city.
“If we can get diverse populations in the city of Milwaukee to become EMTs to then work on the city of Milwaukee serving diverse communities, you can’t even argue with the non-fiscal benefits of this,” Lipski said.
Those willing to work seem to already be answering the call.
“I was watching the news story in 2019, I believe about a shortage of EMTs and just how the system in Milwaukee was kind of rocky, so right after that I got into school and called up Bell,” Nation said.
Both Bell and Curtis are actively recruiting EMTs to work on their ambulances right now. If you or someone you know is interested in a career in the healthcare field, you can visit their websites to learn more about open positions.
Click here to see jobs at Curtis Ambulance.
Click here to see jobs at Bell Ambulance.