By Joseph V. Maruca
My fire department, the West Barnstable (MA) Fire Department (WBFD), has been providing advanced life support (ALS)-/paramedic-level ambulance services to our community since 1974. We initiated our service shortly after Los Angeles (CA) County initialed its more famous paramedic program. Our community has 3,200 residents across 14 square miles, operating one ALS ambulance that transported 270 patients to the hospital in 2018. Because of our long experience as a small, mostly volunteer ambulance service, we often get questions from other small fire departments wondering if they should also take on the role of ambulance provider for their communities.
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在大多数情况下，这些部门都考虑开始或接管救护车服务，因为他们认为救护车账单的收入流将有助于支持消防部门；通常情况并非如此。在大多数情况下，小部门不会通过提供救护车服务来获利。这就是为什么在小社区中最好的消防部门出于非财务原因来接受救护车服务的原因，例如提供比其他优化的服务。
In any case, small volunteer fire departments need to consider not only the financials, but also the operational, administrative, and cultural changes that adding ambulance service to their mission will bring.
Start with the financial aspect. If your department is considering becoming an ambulance provider, you need to know how many patients you will transport to the hospital each year. This is critical to determine your ambulance billing revenue. Your best source for this information is from the agency that currently provides ambulance transport for your community. If that agency won’t provide the information (and you can’t force them to provide it), you’ll have to estimate the number of patients based on a comparison to other similar communities.
Next, know what percentage of your annual patients will be paying their ambulance bill with Medicare (or another similar government insurance plan); with private insurance such as United Health Group, Cigna or Blue Cross; or if they will pay out of pocket because they don’t have insurance. Each of these categories will pay your service a different rate, and you will experience a different collection percentage from each of these categories.
For instance, in 2018, 171 of the WBFD’s system’s patients were on Medicare, 73 had private insurance, and 21 paid out of pocket (no insurance). Medicare only pays us $420 per patient, so our gross income transporting Medicare patients equaled $71,468. The much smaller group of 73 patients with private insurance paid us a total of $173,076, or an average of $2,522 per patient. The 26 self-pay patients paid us a total of $14,883, or $572 each. The importance of this analysis is that Medicare (or other government insurance) and patients who pay out of pocket contribute much less to your income that private insurance patients do. Although we bill everyone the same amount for a trip to the hospital, what we actually collect varies greatly depending on these factors.
Now, you may be thinking, “Wow, $259,427 in ambulance revenue. This is a great reason to go into the ambulance business. Just think how much more money that is for our fire department.” However, you need to stop and calculate your costs of providing an ambulance. Unfortunately, many fire departments focus on how much revenue the ambulance will produce, but they fail to look too deeply at the expenses.
In FY 2018, the WBFD spent $8,693 on medications and $12,584 in disposable medical supplies. Then there is the cost of the ambulance itself. If you keep an ambulance for 10 years, you need put aside about $30,000 per year to purchase the replacement unit. Then there is the cost of the portable equipment: a stretcher system for $30,000, a monitor-defibrillator for $27,000, a stair chair for $3,500, first-in bags, triage kits, portable oxygen, portable suction, and much more. We easily have $75,000 worth of portable equipment on our ambulance; when amortized over 10 years, that’s another $7,500 per year in cost. There’s insurance, fuel, preventive maintenance, disinfecting/cleaning, licensing, repairs, and multiple radio systems. All in all, it costs us about $80,000 just to own the ambulance without staffing it, training our staff, and administration.
Over the years, as the public has come to expect better and faster service, we’ve had to hire a paramedic/firefighter to be on-duty 24/7; this eats up all of the rest of our ambulance income. Having one person at the fire station to get the ambulance out fast means covering 168 hours per week. At $25 per hour, this equals $218,400 per year—without even factoring in benefits. Staffing just weekdays from 8 a.m. to 6 p.m., which we did for 20 years, cost us $65,000 without any payroll costs or benefits.
If you think, “$25 per hour is too much,” keep in mind that, in the northeast, this is not the case. Right now, our department is struggling to find firefighter/paramedics or firefighter/emergency medical technicians (EMTs) to work shifts at $25 per hour. This situation will vary greatly from one region to another. However, the amount you can charge and collect will vary greatly by region. In parts of the country with lower wage rates, what you can charge will be lower. It is essential to know your labor market.
而且，是的，您可以在没有任何付费员工的情况下运行救护车。我们搬到了24/7的人员配备人员，因为我们花了16-18分钟才能在周末和晚上接听救护车的电话。我们的社区发现这是不可接受的。今天，我们在七分钟或更短的时间内将救护车和医护人员送给患者。我们的人员配备成本非常受社区对他们希望我们到达的速度的期望。在开始救护车服务之前，请确定您的“ 90％的时间”响应时间将是什么，以便您为公共和政治领导人设定现实的期望。
In addition to direct financial cost, providing ambulance service comes with high resource and administrative costs. We invest a great deal of time training for emergency medical services (EMS). The WBFD’s typical member spent 25 hours participating in EMS training last year. On top of that, there are uncalculated hours spent training new volunteers to drive and operate the ambulance. We do daily drug and equipment checks on the ambulance as well as comprehensive operational checks on the ambulance twice a week. Our staff spends hours each week writing EMS reports, and we need specialized software for patient reports. We also need a part-time administrator to manage billing, regulatory compliance, records management, and licensure data tracking.
救护车服务将改变您部门的文化。您是否允许人们成为EMT/医生，只有消防员（我们这样做），或者您要求每个人都做两者？这是一个艰难的人事决定，将保持不安和辩论。您将面临倦怠问题，因为EMS将等于紧急电话的65-70％。想象一下，您的志愿者突然有三倍的紧急电话！您是否有三倍的志愿者来处理工作负担？
So, why do we provide ambulance service? There is no other agency that will provide an ALS ambulance in seven minutes, 90 percent of the time, to the people of our community. We do it because it’s what’s best for our community, not because we think we can make money.
Joseph V. Maruca是鳕鱼角的组合消防局西部巴恩斯特布尔（MA）消防局的负责人。他从1977年开始担任志愿消防员，直到2005年成为首席。他是国家志愿者消防委员会（NVFC）的主任，并代表NFPA 1917技术委员会的NVFC。Maruca还是Yarmouthport的Crowell律师事务所的退休律师，也是专注于房地产规划领域的律师。
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