Emergency medical services departments facing an emergency of their own
Referendums to support funding EMS programs are expected to increase in Wisconsin to keep operations going
(WSAW) - Tuesday, voters in the Village of Birnamwood will decide whether to approve a referendum to increase the village’s levy limit to pay for emergency medical services. It is a question more municipalities are having to ask voters around Wisconsin.
The Wisconsin Office of Rural Health released its findings from a recent study last month. It anticipates 38% of communities around the state will have to go to a referendum in the next year to pay for EMS. The study was conducted through a survey asking questions of EMS departments. The survey received two-to-three times more responses than most of the office’s other past surveys, with more than half of departments around the state responding.
“Thirty percent of the services in the survey reported that they don’t currently have enough funding to make it through 2023,” James Small with the ORH said in his testimony to a state Senate committee shortly before releasing the findings. “At some point, they’ll scrap around and they’ll figure this out, but ultimately, that’s not a sustainable way to operate a service.”
Birnamwood is one of them.
“The village itself didn’t have enough money to cover, you know, those additional costs,” Mike Sprague, village president, and chair of the emergency services board explained. “So to do that, we had to, you know, generate more revenue, raise our levy, and the only way we can do that is through a referendum.”
The question facing Birnamwood voters:
Under state law, the increase in the levy of the Village of Birnamwood for the tax to be imposed for the next fiscal year, 2024, is limited to .852%, which results in a levy of $171,802. Shall the Village of Birnamwood be allowed to exceed this limit and increase the levy for the next fiscal year, 2024, for the purpose of increase in cost for emergency medical services, by a total of 18.348%, which results in a levy of $203,325.00, and on an ongoing basis, include the increase of $31,523 for each fiscal year going forward?
Sprague explained the numbers for what the village sees coming in compared to the costs associated with operating the emergency medical services do not add up. As mentioned in the question, the levy is more than $171,000.
“To have our two full-time EMTs 24/7 costs $290,000; ($171,000) doesn’t cover it.”
About two years ago, he said the village and surrounding communities began meeting about this issue as it continues to worsen. The department, before the second half of 2022, was entirely volunteer-based, meaning no pay outside of maybe a free meal from grateful community members.
“We were actually, for a time, having some trouble getting people to respond, especially during the daytime. ” Tim Lemke, a Birnamwood ENT and former service director for the department said. “We’d get a call and then 10 minutes later, nobody was around even to respond or anything, and then they called for mutual aid.”
Nearly all of the volunteers staffing the department work full-time outside of the on-call area in neighboring communities like Wausau. Most work jobs that operate within typical daytime hours.
Sprague said the stakeholders came up with several ideas during their meetings, but it boiled down to making Birnamwood EMS a full-time 24 hour, seven-days-a-week service with a paid-on-call staff. This means the volunteer staff needed to operate an ambulance would be paid to be on-call and would get paid when they went out on a call. The costs of operation would be divided between the eleven municipalities the department services based on population and call volume to each area. Birnamwood taxpayers have the largest share since it has the largest population and highest call volume due to hosting the three nursing homes in the village.
“Since then, we’ve only had one four-hour black hole time that we were out of service,” Lemke said, “which is a far cry from where we were last couple of years.”
During that window, he said the department was down an ambulance and staff was at the department’s sister station in Mattoon, not close enough to meet the required eight-minute response time. Mutual aid had to be called so assistance to the caller could be provided.
“Murphy’s Law,” Lemke added. “I figured as soon as we went out of service, figured something would happen and it did.”
“It’s been a tremendous boost to our service doing what we’ve done,” Lemke continued about the change to the 24/7 paid-on-call service. “We can guarantee that we have one ambulance to respond to a call, and then if there is a second call, then we would try to-- we would page out for our second ambulance. And if we don’t have anyone available to staff it then we would request mutual aid from a neighboring service.”
They still are in need of more volunteers, as the shifts are handled by certain people more than others.
“Trying to get more people in to help give these other people a little bit of a break here and there so they’re not burning themselves out,” Lemke added.
While the paid-on-call service has been an improvement from the fully volunteer nature of the department, Sprague said he would not call it a living wage. Those on-call also have to remain within eight minutes of the station. In many communities like Birnamwood, that means those individuals cannot get basic chores done, like fully getting groceries.
“The real basics we can handle because we have Dollar General in town, but if you’re looking to do like your week’s grocery shopping, then no, you’d have to do that when you’re off schedule.”
They have to find a window when they are off-call and not working their other full-time job. One EMT who works full-time as an EMT at a career service said he accrued his vacation time limit at his full-time job, so he took the paid time off and made himself available to Birnamwood’s services. His wife, now retired, is often his partner on Birnamwood’s calls.
“They basically ended up having no personal or family life and they’re just getting to the point where they’re going to want to quit,” Sprague, a volunteer firefighter, said generally about the strain on the volunteer staff.
To bridge the funding gap for the time being with the change mid-last year, Sprague said the village did the only other thing it could do to bring in more money for EMS: get a general obligation loan through a local bank. It does not require voter approval, but going forward, Sprague said that voters should have a say, which is why they created a referendum.
A ‘Yes’ vote will raise the levy limit by about 18%, or $1 per thousand dollars of property value. The typical home in Birnamwood is valued at $142,000, so if passed, most people would see their taxes go up about $142.
Sprague expressed the hope that the service will be able to reduce the amount of taxpayer funding by the revenue the service generates from its calls, but many consider Medicare and Medicaid reimbursement rates to be low.
A ‘No’ vote means the village would have to make spending cuts in other departments, including services like fixing roads or reducing plowing services. They are cuts that are not uncommon for other municipalities facing the same issue, according to Mike Koles with the Wisconsin Towns Association during a recent Senate committee hearing.
Towns are required to provide EMS by law; in villages and cities, the service is technically optional, though most, if not all, do in some form. So, since Birnamwood covers some towns, by law it has to provide the services whether the money is there to keep it operating somehow. Sprague said if the referendum does not pass, they would likely have to try to contract their services with larger, neighboring municipalities like Wausau, Weston, or Antigo, or with the nearby hospitals.
“Those costs probably would be higher, not maybe necessarily to the village itself, or the surrounding communities, but to the patients themselves,” he noted about the response times. “Life could be at stake. They are at stake anyway, but the longer it takes to respond to those types of calls, the less chance of survival, you know, the patient will have. We hope we don’t get in that situation, but we don’t know. That’s why we’re trying our best to keep our local service going.”
A broad problem
Those neighboring services are strained too.
“One of the things that’s happened in Langlade County, within the last five years or so, we’ve had two volunteer ambulance services go out of business,” Asst. Chief Corey Smith with the Antigo Fire Department noted. “We’ve had to take those areas over because of it. So, that’s increased our coverage area; it’s increased our run volume; and it’s increased the amount of transport time that we do have.”
Antigo’s fire department covers nearly all of Langlade County -- about 700 square miles. Pickerel is the only other agency charged with handling a couple of communities in the county. Call volumes are increasing too, in part due to a larger aging population.
Smith said they as a, mostly, career service, meaning full-time paid personnel with benefits, do not have the severity of the issues volunteer departments have been facing, but the shock waves ripple. Like the volunteer departments, staffing is a challenge; the city is down five people.
“What we’re starting to see is a higher probability of two ambulances or more being out at the same time from our department and then not having anybody for the next one, which is kind of a rarity for us.”
He said his staff is conscious about ensuring that does not happen, but that means more overtime.
“Our personnel are often being asked to work 48-hour shifts or even 72-hour shifts to cover some of those overtime costs or overtime slots, in order to have the proper amount of staffing,” he explained. “We have room for six people on a crew, that would be our ideal staffing. We can operate with as low as four, and if we go below four, that would require us to hire somebody back on overtime. So we’ve had to do that a lot with vacation seasons and stuff like that.”
That time and a half pay hits (sic) local taxpayers. However, hiring staff has become a challenge over the years; where they would once get dozens of applicants trained and ready for the job, now the applicant pool is far smaller with people who only have ENT certification, not the higher, paramedic training the department requires. Or a firefighter that only had his EMS certification. Antigo will now hire the right candidates and pay for their initial training, but that impacts department costs and staffing too.
“You’re paying somebody that you don’t directly have as your frontline staff yet,” Smith explained. “Paramedic school is upwards of about a year’s worth of time, two to three days a week, and then studying. So, we’ve got our personnel that are going through paramedic -- right now we’ve got four of them. And they’re investing not only the time that they have to go to in-person class but then there’s some online meeting times that they’re expected to attend. And then you add on the study time. So you know, probably about an average of four hours a day, at least for them to study, and that takes them out of our daily operations with inspections, the maintenance stuff that we do. You know, and that puts it on the other three people on their crew.”
Smith said they have to remain flexible in order to be competitive, or as competitive as they can be. Recently, Wausau got approved to hire more staff, thanks in part to a state grant program. Smith has considered applying for the same grant to add more staff but says it feels pointless when they cannot fill the five open positions they already have.
“Everybody’s acknowledged it that we are almost robbing Peter to pay Paul, you know, we’re looking at candidates from each other,” Smith commented. “When you have a city, like Wausau that’s hiring, it does certainly have a big impact on what we can draw from and who we can attract to our community.”
Small will soon be retiring from his services with the Village of Palmyra in southern Wisconsin to become the ORH’s EMS outreach program manager full-time. He is the director of public safety and the police services director for the village currently. He knows the struggles first-hand, as he creatively dealt with staffing shortages, problems with training access, and funding issues by implementing a new service model. Nearly all of the village’s first responders are trained as police officers, firefighters, and EMTs, including himself. He said it is a model that could work in some other communities, but it will not work everywhere.
In addition to confronting the challenges in his own role, Small participated in a legislative counsel study to identify the problems in services around the state in 2016.
“There wasn’t a lot accomplished following that. We found that there was a huge issue and there weren’t solutions that were brought forth.”
So, the problems were bad then, but have had a chance to worsen over the last half a dozen years.
“That’s six years of declining volunteerism. That’s six years of less (sic) people available on services or people that are still there, maybe not working two days a week, maybe they’re working one and not having the time to do the rest.”
He said when you factor in vacation or sick time, and regular weekend periods, services need to staff about seven and a half people to be able to run one ambulance 24/7, 365 days, 17,520 hours a year. The ORH’s research found of the respondents, 41% of services are operating with six people or less; 21% only have two-to-three people staffing operations.
This can mean other services are having to cover for neighboring areas if an ambulance is down, there are not enough staff members to go to a call, or all available ambulances in a service area are already occupied with other calls. The report found 78% of responding services provided mutual aid to a neighboring service due to low staffing levels.
“So, you’re seeing this almost cascading effect in some of these systems,” Small explained. Where ‘service A’ isn’t able to respond to a call, so ‘service B’ takes that call. Now, ‘service, B’ is in ‘service A’s’ area. Now, ‘service C’ is taking ‘service B’s’ call, and so on. So, you’re stretching out the system, which on paper looks like it has adequate capacity, but in action, it doesn’t.”
In the state overall, 41% of services said they lacked reliability in having their departments staffed 24/7, 365 days a year in the last year. The problem is worse in rural areas and for volunteer services with more than half from each demographic eporting that, but it is still an issue for urban and paid services too. In the north central region, 45% of services reported they lacked reliable service.
While many people in this profession value the sense of service it provides to the community, not the pay, pay is a factor.
“You have to make choices sometimes too, and having a roof over your head is sometimes taking precedence over those things, especially in these systems where they’re getting paid nothing or next to nothing.”
That is not for a lack of volunteer spirit. Small explained many of the volunteer services began in the 1970s when a federal grant opportunity allowed many communities to purchase their first ambulances.
“I think back to my grandparents where my grandfather worked and he was a volunteer firefighter,” Small recalled. “My grandmother, largely was in the house, not working. And now we move ahead and that’s not the norm at all. In most of our houses, both spouses are working, and both spouses might be working multiple jobs, to pay for the cost of housing in particular. I think that’s where the biggest shift has been in our society.”
When adding in fewer and fewer volunteers taking on more and more calls, often with older staffing who can often be in their 70s and at greater risk of having health issues, the job is taxing.
Small also noted that access to training needs to be addressed. The study found 36% of services overall were more than 30 minutes away from training centers. In rural and volunteer departments, those portions increase to more than half. More than one in 10 rural services have more than an hour’s drive for training. Small stated, especially in rural areas, these trainings can get canceled if there are not enough participants, so those who need to get their certifications either have to wait longer or drive further. This means services are going without trained staff for longer periods than they could if there was better access. Broadband access in certain parts of the state also impacts training availability, though some aspects of training cannot be done virtually either.
Municipalities, for a number of reasons including EMS, have asked the legislature to increase shared revenue.
“The state has been reducing our shared revenue for the last 20 years, and we’re getting squeezed tighter and tighter all the time,” Sprague urged. “But the requirement and the need for services is increasing, and the cost of those services and everything we do is increasing.”
He said the 4% increase that as been murmured throughout the state’s budget planning process will not cut it. He would like to see the percentage that has been cut back so municipalities can pay for these services without depriving citizens of other necessities like repairing roads.
“We’re kind of caught between a rock and a hard spot,” he concluded.
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