Before you start judging one versus the other, we need to address the pros and cons of each type of EMS system. 

I started my career in a county based system, and both my dad and step-dad worked in county based services.  It wasn’t until I moved to Georgia that I saw a private ambulance service holding a 911 contract with a county.  At the time, Dekalb County just announced that they were disbanding their ambulance division and contracting with American Medical Response.  This was the first time I had heard of anything like this, and it quite honestly blew my mind.

How could a FOR PROFIT company run a 911 service?

For everyone in this area, this was completely normal since services like Grady EMS and Metro Atlanta Ambulance Service hold multiple county 911 service contracts.  Don’t get me wrong, there are numerous private ambulance services like AMR in Charleston, South Carolina, but none of them hold 911 contracts.  The “tri-state” area consists of Charleston County EMS, Berkeley County EMS, and Dorchester County EMS, all of which are county based systems.  You may have even seen Berkeley County EMS featured on A&E’s “Live PD” television show.

Private EMS in the area is reserved for inter-facility transfers between the hospital owned urgent cares, skilled nursing facilities, and psychiatric facilities.  So you can guess my level of confusion when I moved to Atlanta to find very few county based systems.

So, why is this approach is gaining popularity in population dense areas?  As to avoid any controversy, I won’t state any information about specific county’s contracts.  This will be a broad overview of the most common type of county contract.  For the most part, most counties divide funding between all of the different departments, this includes the fire department and EMS department if they have one, however most departments keep them together. So let’s say the county’s fire department budget is one million dollars.  Half of this funding goes to fire department supplies and equipment and the other half goes to EMS.  That doesn’t leave either department with very much money.  To put this into perspective, the average fire engine costs anywhere from $100,000-300,000 for the vehicle alone, not including the equipment it needs.  The average cost of an ambulance is about $120,000-150,000, not including equipment as well.  So how can the department save a little money and use it for other items they may be in need of? 

EMS services are billable in most states, and transports typically cost anywhere from $400-1,200 plus mileage.  But here is where it gets funky…

Most 911 calls go unpaid!

Yes, that’s right.  Running a 911 ambulance is not very profitable because a majority of patients and their insurances do not pay their bills.  So why do private ambulance services take 911 contacts?  Well, to be blunt, it just about guarantees them contacts with the hospitals in the area for their intra-facility transports.  It’s an unspoken rule that whoever brings their patient’s to these hospitals, also gets rewarded with a contact for transports out of the them.  It also makes sense that the service that has the 911 contract will also have a large amount of ambulances in the area.  So, with those patients if the bill goes unpaid, the service will charge the hospital and they will pay a reduced fee. So long story short, if the patient doesn’t pay the ambulance company the hospital will, so it’s guaranteed payment.  Holding 911 contracts also attracts EMTs & Paramedics who want to run 911 calls, instead of just transports, so it in a way guarantees staffing too.

So back to our county based service.  They don’t have these intra-facility patients “padding” their wallets.  They have a legal obligation to transport anyone in need, but rarely make anything back.  This KILLS their budget.  So, an easy solution would be to get rid of 911 ambulances, right?

Well, that’s exactly what they do.  By contracting with a private service, the county is able to pay a minimal fee (if any) to the ambulance service to cover their county.  That way, the remainder of the budget is moved into the fire department’s budget.  This saves the county money.  This also works in the ambulance service’s favor for the reasons we’ve already discussed.  So win-win right?

Financially, this makes sense, but it doesn’t always work out the way it’s supposed to.  Remember when we said 911 calls don’t bring in money?  Well, let’s say that you own A+ EMS, and you have a contract with Anywhere-Ville County for their 911 district and Anywhere-Ville Medical Center for their intra-facility transports.  A+ EMS has 20 ambulances, 10 are “911 trucks” and the other 10 are “transfer trucks”.  It’s a slow 911 day in Anywhere-Ville, and only one of your “911 trucks” has run a call today.  But the same can’t be said for the Anywhere-Ville MC.  They are discharging patients left and right, and your service is getting backed up.  Instead of telling Anywhere-Ville MC that you can’t get a truck to them for at least a couple hours, you decide to send a couple of your “911 trucks” on intra-facility calls, since they are just sitting around anyway.  So you decide to pull 4 trucks from your “911 division”.  But a couple minutes later there is a MASSIVE plane crash and you only have six ambulances available.  Now anyone reading this probably saw this coming, but this is what happens on a grand scale.  It’s nothing against private EMS services; they are just trying to do their best with what they have.  But at the end of the day, the priority is going to getting the job done.  Unfortunately, sometimes it doesn’t work out with the best results.

However, with a county based system, you should have trucks available (most of the time), but you are going to be paying them to sit until needed.  Like I said, financially, this doesn’t make sense.  Therefore most departments are going to use private EMS services to save money, but it comes with a cost.

Now, I don’t want to seem like I am just dogging on private EMS, because I’m not.  Some county run services do not have the appropriate funding to support an EMS service, therefore the county is in deep trouble.  So when a private EMS company is brought in, response times improve and things seem to get better for a short period of time.  But like clockwork, eventually the same thing will happen as we discussed.  Unfortunately EMS is doomed to fail, just because of how it was incorporated.  For the most part, most patients that need EMS won’t call us, and the ones who don’t need us will call us.  It’s just part of the job, and we can only do the best we can.  Until society decides to place EMS on a higher priority level and to use the service appropriately, we are bound to repeat this over and over with the same results