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Traditionally, the goal of emergency medical services (EMS) is to provide immediate medical assistance and rapid transportation to a medical care facility, as well as to make available coordinated inpatient and outpatient treatment so that the most seriously injured or ill are quickly triaged to specialty facilities. In addition, EMS providers commonly deliver emergency medical dispatch-care instructions by phone for emergency victims prior to arrival-as well as injury prevention and rehabilitative care.

In many rural areas, a rising aging population, increasing numbers of earlier discharges from hospitals and the closure of many hospitals are influencing a growing demand for emergency medical services. Often, these rural communities suffer from inadequate access to other medical resources, and EMS becomes a safety net for a broad array of non-urgent health services including primary care. However, the strain of delivering EMS in several rural areas-where morbidity and mortality rates from serious injuries is higher than in urban areas-has reduced expectations that emergency care in such settings will always be fast and effective.

Growing concern over the effectiveness of rural EMS recently prompted the federal government to commission an opinion survey of state EMS directors on the issue. The unmet needs for rural EMS most identified by state officials was the recruitment and retention of EMS personnel, followed by appropriate medical oversight and financing of local EMS programs. In particular, experts site the following reasons why emergency medical care in rural areas often is not as highly developed as in some urban areas:

Sparse populations in large geographic areas increase the cost of maintaining emergency medical services, making it impossible for many rural local governments to fund EMS programs through taxes. In any locality, the most significant costs of delivering emergency medical services are born by communication systems, vehicles and equipment, personnel training and continuing education, medical direction, and state and local regulations affecting staffing and licensing.

Nationally, most EMS programs are supported by a combination of public and private funds. Federal and state subsidies commonly derive from general tax revenues, service fees, special revenue (such as motor vehicle violations or vehicle/driver licensing) and other sources. Third party payers, including Medicare, Medicaid, private insurance, private pay customers and special service contracts, may also be an important revenue source. Some EMS activities are funded through subscription agreements that allow consumers to pre-purchase emergency medical services. Most rural communities do not have the profit potential and volume of business to operate private sector emergency medical services, and-as such-are left with a limited amount of public support for EMS.

The relatively low volume of emergency calls in rural areas, in relation to the high overhead of keeping a prepared staff, leads to an abundance of EMS squads staffed by volunteers, and consequently, to a less stable and often poorly managed EMS organization. Some insurers tend to under-reimburse such programs for this reason¹, and many volunteer squads in rural areas do not even charge for their services because they lack billing expertise or they simply view their function as one of public safety.

Difficulty in Recruiting and Retaining Emergency Personnel

Recruitment and retention of all medical personnel is difficult in rural areas. Contributing factors include lower pay/benefits, outdated facilities and equipment, long hours, lack of collegial support, and poor access to social amenities. In rural areas most needy of EMS, career personnel are in severe shortage because of low-volume work and scarcity of resources. Such conditions have made many communities unable or unwilling to support paid EMS staff.

In addition to low wages or uncompensated service, other factors attribute to a high turnover rate among rural EMS personnel and marginal performance in their duties. These include inadequate physician participation in care and service delivery, lack of a satisfactory career ladder, inadequate leadership and training support, and insufficient equipment and supplies. Because many rural EMS personnel are volunteers, finding time to conduct training is difficult, and service coverage can be erratic at times. Moreover, stringent licensing requirements and regulations governing EMS services and personnel in some states places additional pressure on many rural EMS programs.

Effective public safety communications systems commonly include:

• Timely dispatch of EMS and other public safety services;
• Coordination among EMS and other public safety agencies;
• Access to medical direction;
• Communications to/between emergency medical facilities and between EMS and other health care providers; and
• Outlets for disseminating information to the public.

Most rural EMS providers lack such an adequate communications infrastructure. For example, rural EMS programs typically have a longer response time to emergency calls than do their urban counterparts due to poor roads and difficult terrain, sparse populations, long distances, limited telephone service, inadequate public education, and insufficient resources to support reliable radio communications or advanced emergency call systems. EMS personnel (both rural and urban) are relatively isolated-communications wise--from the rest of the health care delivery system. They have little or no access to medical records or other medical history about their patients that would be helpful in making more efficient and qualified decisions. Furthermore, rural EMS dispatchers (those who dispatch services and provide pre-arrival instructions for care) often need more specialized training in order to provide effective and efficient pre-arrival instructions for care.

In many rural areas, the "911" emergency call system is not always available due to economic conditions or an inadequate number of telephones. In some states, as much as 85 percent of the population does not have access to the "911" system. When required to dial a 7-digit number to access emergency assistance, studies find that it is more likely that callers will forget the number and that it will take longer for assistance to arrive.

Traditionally, the organization, delivery and financing of emergency medical services has not been effectively integrated with other parts of the health care system.² In general, the goal of an integrated health care system is to achieve greater continuity of medical services and increased efficiency in delivering them. As such, experts suggest that EMS would benefit from integration in the following ways:

• More efficient referral and/or transport of patients to the most appropriate facility;
• Reduction of costs and improvement of medical services in general, in that EMS could become more geographically widespread, highly mobile, and an accessible source of specialized information; and
• Fulfillment of a broader primary care and public health role in rural areas when integrated with large health systems.

The integration of EMS with the larger health system is particularly challenging in rural areas. The geographic separation of health system components and the lack of communication and networking between them are common in most rural communities. Local rural EMS and health care providers are not likely to find ways to work more effectively together without outside assistance.

While attention to the plight of rural EMS has grown among public policymakers, no significant remedies have been instituted. Major federal legislation introduced in the late 1980s to create a program of grants for states to improve the quality of their rural EMS systems was not enacted. Certain concepts from this legislation became part of a 1991 law (Trauma Care Systems Act); however the bill's roughly $5 million appropriation and several set-asides for rural projects and areas had little impact. Most recently, the federal government has approved a new national Medicare fee schedule for ambulance transports, due to go into effect in January 2001. Experts believe that the single flat payment rate will have a mixed blessing for rural EMS providers that are more dependent on Medicare than their urban counterparts. Volunteer providers now constrained by little or no payment will benefit, but full cost EMS providers are expected to suffer under the new rate schedule.

Some clear opportunities exist for state policymakers to improve rural emergency medical services, including:

1. Developing incentives for local EMS programs to become more integrated into the larger health care system.

• Broadening the scope of pre-hospital emergency care provided (i.e., EMS staff would take on a more advanced medical function with patients before they reach the hospital, rather than just stabilizing and treating symptoms while in transit and deferring treatment till they reach the hospital.). For example, EMS personnel may become more involved in staffing enhanced regional poison control centers;
• Delivering triage for severe injuries or illnesses as well as providing on-the-scene care with a follow-up visit to a clinic for less severe injuries, and
• Serving a more public health function that improves access to basic health care by performing immunizations, sports and preschool physicals, blood glucose testing, hypertension screening, and community education on self-care and prevention for such matters as managing children's illnesses, diabetes and epilepsy education, and injury prevention.

1. Providing adequate funding for EMS initiatives.

Many experts agree that an appropriate level of public support for EMS should be based on systems that compensate EMS providers for preparedness to respond to emergencies, rather than by the total number of responses or transports they perform. If EMS providers are compensated for preparedness, experts believe that these providers would then have (or should have) adequate funding to become an integral part of the medical services network in a rural community.

2. Supporting effective strategies to recruit and retain EMS personnel in rural areas.

• Establishing statewide or regional EMS offices to coordinate and fund management and clinical training of local EMS personnel and to provide technical assistance in recruitment and retention of EMS staff. For example, state support could be used to train staff on effective reimbursement practices or to establish contracts between local EMS offices and third party billing agencies. Statewide or regional offices could also assist local EMS programs with support in recruiting area physicians critically needed for medical direction of a largely volunteer EMS workforce in rural and frontier communities;
• Providing financial support (e.g., grants, low-cost loans) for "core" local EMS personnel as well as for certain equipment and supplies so that personnel, particularly volunteer staff, do not have to pay for supplies or their own training; and
• Supporting demonstration projects that expand the skills and scope of practice for certain rural EMS personnel and offering greater flexibility in the licensing requirements for volunteer EMS staff to foster personnel recruitment and increase the volume of emergency medical services.

1. Improving public access and communications systems.

• Encouraging the implementation by local governments and public utilities of enhanced "911" emergency call systems in all areas. Enhanced "911" service gives EMS geographical location information on the caller; regular "911" service simply provides the caller's phone number. In rural areas where some residents cannot afford telephone service, subsidies for local governments and public utilities could be made available to provide limited phone service; and
• Funding improvements in the infrastructure and technology of EMS communications systems, including improved Internet access, better links to telehealth and distance learning resources, and enhanced training of EMS dispatchers. Since response time to emergencies in rural areas typically is longer than in urban communities, pre-arrival care provided by emergency medical dispatchers could be crucial.

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