What if you called 911 for an ambulance, and no one answered?
In rural Berkshires, where some towns are half an hour drive from the nearest hospital, alarming trends in emergency medical service finances has made that hypothetical scenario a bit too close for comfort.
The funding for life-saving services, and the people who provide it, remains a growing problem for Berkshire County’s ambulance services, whether they’re run as nonprofits, private companies or town departments. Absent support from a state that does not regard EMS as an “essential” service, local rescue squads are looking to private donors or local governments for help.
“The way these services are funded is a nightmare. It makes no sense,” said state Sen. Mark Paul, D-Becket.
“The way these services are funded is a nightmare. It makes no sense,” said state Sen. Mark Paul, D-Becket.
Northern Berkshire EMS is the result of the merger of North Adams Ambulance and Village Ambulance in Williamstown. The company will take on those served by Adams Ambulance when it closes at the end of the year.
There have already been some close calls, and some services are facing real trouble. Adams Ambulance Service, which serves Adams, Cheshire, Savoy and Hawley, has indicated it is closing Dec. 31, though a last-ditch effort to save it is afoot. And Southern Berkshire Volunteer Ambulance Squad has for the second straight year requested taxpayer funding to close an operating deficit of at least $350,000.
But Adams Ambulance Service isn’t alone in facing financial difficulties. Across the county, town officials and rescue service leaders have cited the same factors: Sharply rising personnel costs, difficulty finding trained staff, inadequate reimbursements from Medicare and Medicaid, unfunded government mandates and even gamesmanship from some insurance companies.
“We’re already in a county that is not overly staffed with ambulances,” said Brian Andrews, president of Pittsfield-based County Ambulance, a family-owned for-profit service. “There are ambulance deserts here — towns don’t have their own and rely on others. This situation has the potential to increase those.
“We’re already in a county that is not overly staffed with ambulances,” said Brian Andrews, president of Pittsfield-based County Ambulance.
“People are accustomed to short response times and good quality EMS care,” he said. “There’s no way that’s not going to be affected when you have [fewer] ambulances available to respond.”
A COUNTYWIDE PROBLEM
When the nonprofit Adams Ambulance Service announced it would be ceasing operations on Dec. 31, it sent a shock wave through Northern Berkshires. Leaders quickly heard from constituents seeking assurances that emergency medical service would still be there and arrive in a timely fashion.
The three towns announced an agreement with North Adams-based Northern Berkshire EMS in which the service would base an ambulance and crew in Adams. Adams officials voted to approve that arrangement on Thursday.
Leaders in Adams and Cheshire said they have known since March 2022 that a problem was brewing. When Adams Ambulance said it was running a $200,000 deficit in September, it was too late to ask taxpayers to help save the nonprofit, Adams Town Administrator Jay Green said.
Southern Berkshire Volunteer Ambulance Squad has for the second straight year requested taxpayer funding to close an operating deficit of at least $350,000.
Southern Berkshire Volunteer Ambulance Squad, which sought and received a total of $350,000 from the six towns it serves at town meeting this year, announced last month that it will seek at least that much, if not more, in the coming year.
“We are not in dire straits. We’re not going to close tomorrow or next week,” said James Santos, president of the nonprofit’s board of directors. “But we can’t continue the model we had forever without getting more and more support from our member towns.”
Other Berkshire ambulance services have faced similar challenges:
- In April 2021, the Dalton Fire District assumed operations for Dalton Ambulance and Rescue when that group said rising equipment and insurance costs and a declining volunteer pool made the move necessary. Federal Form 990 filings show that in fiscal 2021, Dalton Ambulance program revenues fell 28.4 percent from the previous fiscal year, while expenses rose 6 percent over the same period.
- Northern Berkshire EMS came to exist through a 2018 merger between North Adams Ambulance and Village Ambulance of Williamstown, which found itself in deep financial trouble in 2017. Form 990 filings show Village Ambulance finished calendar 2017 with a $364,899 net loss.
- The Otis Rescue Squad, a nonprofit, and Becket ambulance, a town department, are studying potential collaboration or merger. Both services are limited by personnel, and Becket, which allocated $355,724 for the service this fiscal year, is looking at an ambulance purchase in two years that could cost as much as $425,000, Town Administrator Katherine A. Warden said.
- In Washington, the Select Board is considering whether to contract with Becket at a rate of $400 per call or renew its expired contract with County Ambulance. Last year, the town had 30 calls for service.
But what about the for-profit model?
“We’re running close to the line right now,” Andrews said. “It is the most concerning it’s ever been in 40 years we’ve been in business.”
A BROKEN MODEL
Across the county, ambulance service leaders and lawmakers laid out the picture of a vital public service with a broken economic model.
“This has been the impending storm we’ve been talking about for a long time,” Andrews said. “COVID pushed us over the tipping point. … This is not a surprise. We’ve been talking about the reimbursement model being broken for years.”
Some say a fix to the broken economic model is that the state must deem emergency medical service “essential,” as it does for police and fire departments, thereby making state funding possible.
Reimbursement, or lack thereof, is a sore point with county ambulance services, and it’s gone beyond private and public insurance failing to cover the full cost. Multiple providers said private insurers no longer reimburse in a timely fashion.
Andrews said some carriers have weaponized that dynamic to squeeze lower reimbursements out of providers. He cited this example: On an unpaid bill of $585 that hit his desk this month, a company that negotiates for insurance carriers offered, via fax, to pay County Ambulance within 10 days — if it was willing to take less money.
“There was a time I used to do these. I’d get the money in 10 days,” Andrews said. “But it got to a point I can’t afford to do it any longer.”
Northern Berkshire EMS sees some hour-long ambulance rides. Plans to reopen the North Adams Regional Hospital could cut those in half
As for the government, the federal Centers for Medicare and Medicaid Services, which sets rates for those two programs, has raised reimbursements 17 percent between 2006 and 2023, Andrews said. But expenses, driven by inflation, far outstrip that increase, he said. A CMS review of reimbursement, delayed by COVID, is underway, Andrews said.
“In the early 1990s when we first started doing paramedic level [service], most meds were $5, $10, $25,” Andrews added. “Now we have meds that can cost $1,000 an injection.”
What’s worse: If ambulances don’t transport a patient on a call, there’s no reimbursement at all. In the eyes of Andrews and others in EMS, that’s a missed opportunity; they say paramedics could treat more patients on scene, preventing expensive and time-consuming emergency room visits.
“We’re not like the doctor’s office open during the day — we’re open 24 hours a day,” Andrews said. “We don’t have a waiting room — we have to take those calls and handle them the best we can.”
In Berkshire County, the lack of trained paramedics and emergency medical technicians has led to ambulance services raising salaries and benefits to attract and retain personnel.
THE BIGGEST EXPENSE
In Berkshire County, the lack of trained paramedics and emergency medical technicians — the two highest levels of training in a highly regulated profession — has led to ambulance services raising salaries and benefits to attract and retain personnel.
For Southern Berkshire, according to Form 990 filings, in 2013 employee compensation was $282,922, or 31.3 percent of expenses; in 2021, the most recent year available, it was $1,010,496, or 48.8 percent of expenses.
“Staffing is by far our biggest expense,” Santos said. “Finding paramedics and EMTs is very difficult … there’s a severe shortage of both. To retain people we have to keep increasing salaries and benefits.”
The jobs are out there. As of this week, Lanesborough was looking for a basic level EMT, starting at $23 an hour; Northern Berkshire EMS was advertising for multiple positions on its website; and Action Ambulance in Pittsfield was seeking basic and advanced level EMTs.
Training costs for ambulance professionals increase with the level of service. It costs $1,400 for basic EMT certification; full paramedic training costs between $8,000 and $12,000.
Northern Berkshire EMS President John Meaney said he would like to add eight full-time positions and part-time staff to help cover Adams, Cheshire and Savoy.
The pandemic also drove a lot of EMTs and paramedics out of the business, Andrews and Meaney said.
“People who worked very hard decided there’s an easier way to make a living,” Andrews said.
“COVID changed the face of how we operate on a daily basis. If I go back to March 2020, there were policy and protocol changes happening day to day, in some cases hour to hour,” Meaney recalled. “It was very tough on all our providers. We had a lot of providers decide this wasn’t going to be a full-time career anymore. “
Staffing costs and shortages also prevent companies from fully staffing their “rigs,” as ambulances are known in first responder circles. Southern Berkshire has three ambulances, but fully staffs two, Santos said. Lee Fire Chief Ryan Brown said his town-funded department, which serves Tyringham, part of Stockbridge and about 20 miles of the Massachusetts Turnpike, has two rigs, but can only afford to staff one.
Staffing levels are set in state law according to the level of service provided — and those training standards are defined by state law, as well. For basic life support, an ambulance needs at least one EMT certified at the EMT-Basic level, and one person trained to the first responder level. Generally, the certification requirements increase with the level of service.
Lanesborough bought a brand new ambulance to serve the town and the county back in 2022.
Staffing two ambulances would be a “no-brainer,” Brown said. There’s never a shortage of work to be done, he said.
“But when you look at the costs including benefits to hire eight more people to staff that second ambulance 24 hours a day, seven days a week, you’re looking at close to $600,000 just in labor cost,” Brown said.
What’s more, the job description is a tough one: It requires quick thinkers who can obtain certification in lifesaving skills and medical knowledge, are physically fit, are willing to insert themselves into stressful situations where they will see things they cannot unsee, and increasingly, are forced to put their personal safety at risk.
“We have a workforce that is made up of very dedicated hardworking people,” Andrews said. “That’s the other part of this — we’re trying to pay them what they really worth but you’ll never do that, they’re worth more. Unfortunately [the profession] has the highest rate of workplace injuries and stress-related illness because of what they see and do.”
Training costs increase with the level of service. It costs $1,400 for basic EMT certification, Meaney said; full paramedic training costs between $8,000 and $12,000. Northern Berkshire fronts the cost, and the employees pay back 50 percent through payroll deductions, he said.
Meaney would have liked to have seen Massachusetts follow Vermont’s lead and funnel ARPA dollars into fully funding EMT training. That was a missed opportunity, he said.
FIXING A BROKEN SYSTEM
How to fix the problems facing ambulance services remains a moving target.
Adams announced an agreement with North Adams-based Northern Berkshire EMS in which the service would base an ambulance and crew in Adams.
Some say the state must deem emergency medical service “essential,” as it does for police and fire departments, thereby making state funding possible. Others say absent that change, communities long served by nonprofit rescue squads must step up and absorb part of the cost.
Andrews noted that several states have passed or are pursuing legislation that would allow for the setting of reimbursement rates at the local level. In the Massachusetts Legislature, two bills — S.717 and H.992 — would enforce full reimbursement, and S.717 proposes locally set reimbursement rates. Both bills are still in committee.
A lack of state support for EMS funding is not a Massachusetts-only problem. Despite the fact that it saves lives, emergency medical service is only regarded as an “essential” service worthy of state funding in 13 states and the District of Columbia.
In an email, the Department of Public Health confirmed that EMS is not considered an “essential service” in Massachusetts, which means there is no requirement for a community to provide coverage. That troubles local EMS leaders.
“When someone dials 911 they want one of three services, not two,” Santos said. “That’s kind of a slight to the employees and people who work in EMS, I think.”
In Lee, Brown would like to see that change, as well. The lack of eligibility for state cofunding “does make it difficult for everyone — not just the small companies but the big companies also,” he said.
A lack of state support for EMS funding is not a Massachusetts-only problem. Despite the fact that it literally saves lives, emergency medical service is only regarded as an “essential” service worthy of state funding in 13 states and the District of Columbia.
“We’re very fortunate in Lee that we are underwritten by the tax base,” Brown said. “If we had to operate as we currently do based on our revenues we probably wouldn’t be able to operate the way we currently do.”
The DPH requires that cities and towns must have an approved EMS service zone plan, including average response times, and further requires that EMS agencies must have backup agreements.
A number of small towns, including some in Berkshire County, are covered by multitown service zone plans, according to DPH. But Andrews noted that there’s no penalty for failing to have one. A 2022 listing of towns with service zone plans notes five county towns do not have one: Adams, Dalton, Hinsdale, Richmond and Windsor.
‘SOMEBODY’S GOT TO PAY FOR IT’
For a century, Berkshire County towns were fortunate to have volunteer fire and ambulance responders, said state Rep. William “Smitty” Pignatelli. Now, he believes regionalization and community funding are the way forward. “I’m not convinced there’s a Beacon Hill solution,” he said
“I’ve never once had to call 911. That doesn’t mean part of my tax bill doesn’t go to pay for services. Towns need to recognize that and factor it into town budgets,” Pignatelli said. “Somebody’s got to pay for it.”
Northern Berkshire EMS doesn’t seek contributions from its member towns but Meaney can envision a time that could happen, especially if the reimbursement model isn’t fixed. That’s where a regional approach helps, he added; the more towns can share the load, the better.
Pignatellii, Paul and other Berkshire County lawmakers said they regularly hear about EMS funding and staffing difficulties. But rural Western Massachusetts problems are a tough sell to lawmakers representing cities and suburbs.
“In 80 percent of Massachusetts the population of this state is not having this issue,” Paul said. “They have their own issues but they’re able to as nonprofit entities to be able to make sufficient revenues to carry on services, whereas we don’t have that same luxury.”
Meaney and Pignatelli both see regionalization as the future, as a means of sharing expenses and eliminating duplication of training and front office expenses.
“Every community this day and age cannot have its own ambulance,” Meaney said. “It’s too costly.”
Ambulance service leaders agreed on one more thing — what happened to Adams Ambulance Service, a 50-year-old nonprofit, and the anxiety that announcement generated, served as an up-close reminder of what can happen.
“EMS is a serious business,” Brown said. “To say that we’re dealing with people’s lives isn’t an understatement.”
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