A person can suffer permanent brain damage or death if no one administers aid to them within minutes after going into cardiac arrest.

The patient’s best chance of survival is a quick response, but for around 140 hours in June, Karns City Regional Ambulance Service was unable to respond to calls due to a staff shortage, requiring other area EMS agencies to instead service the 150 square miles of territory Karns City normally covers.

Mark Lauer, CEO of Karns City Regional Ambulance Service, said his is not the only EMS agency struggling to keep a heartbeat because of financial shortfalls, and the situation could get worse if no solution is found.

“We cover 11 municipalities... last year we sent all them a letter asking for them to place the half-mill EMS tax. Some did, some chose to do an annual donation of equal or greater to tax itself,” Lauer said. “It is imperative that the county come up with a financial solution to our woes, particularly the small services. People's lives depend on having a fast and good EMS service.”

Karns City ambulance started in 2018 when the volunteer fire departments in the area could no longer handle the emergency call volume, Lauer said, and until recently, the service didn’t receive consistent funding from the municipalities it covers.

Conrad Pfeifer, executive director of Quality EMS, which is based in Adams Township, said municipalities are required to provide emergency services, including EMS, but they are not required to fund them through taxes or annual budgeting. He said changing the requirements for municipal funding could greatly improve the financial anguish ambulance services across the county and the state have been facing.

“Everybody thinks we get municipal funding, but not all of us do,” Pfeifer said. “Because they are operating on small or no profit margins, EMS agencies are struggling to pay competitive wages and are losing employees.”

According to Rob McLafferty, Butler County 911 coordinator, there are eight ambulance services based in Butler County, and another four outside the county that respond to certain areas in the county when needed. All of the ambulance services in Butler County have paid staff, but may not receive funding from the municipalities they serve.

He said the dispatch office calls in the ambulance service for a particular region first, but they are not always able to respond.

“If they are called and said, ‘We're out of service,’ we dispatch the next unit,” McLafferty said. “The service decides who their backup is going to be. They have a list of services for each area they cover, and we send them out.”

EMS agencies may be out of service when there is a lack of staff, or when they are responding to other emergencies and don’t have the resources to make it to an additional emergency. McLafferty said an ambulance can be dispatched for a number of reasons, including providing support for fire or police departments.

“Any crash with unknown injuries, there is an ambulance that is going to respond,” McLafferty said. “For fires, an ambulance is notified of any potential victims, and they provide coverage for fire personnel.”

Ambulance services are unique compared to other emergency response units like fire and police departments, which are not legally required to respond to all dispatch calls.

Jay Grinnell, president, director and founder of Harmony EMS, said ambulances can get bogged down in calls that may not necessarily require help from medical personnel.

“If we have a truck available, we must respond. We routinely get calls for people who fall down and they need help to get back into a chair,” Grinnell said. “We're driving an ambulance — that's five miles to the gallon — getting calls as far away as Beaver Falls, Ellwood City on a regular basis.”

Grinnell said Butler County should look for a funding solution for EMS agencies that will allow for them to continue to respond to their call volumes. The other EMS directors largely agreed.

“Somebody's heart attack in Cranberry Township is just as important as someone's in Bruin,” Lauer said.

Some EMS agencies in Butler County have recently increased wages to recruit and retain staff, which is necessary to continue operating but adds to the financial strain.

Kathy Neiper, retired paramedic and one of the founders of Portersville Volunteer EMS, said many ambulance services have not been able to keep pay competitive with other health care jobs. Portersville ambulance also was unable to respond to calls for a period a few months ago because of a personnel emergency.

“It comes down to staffing, but it's hard because you have less people going into EMS,” Neiper said. “People work two or three jobs, if they are a medic, to be able to live.”

Pfeifer also wrote in a letter to the municipalities covered by Quality EMS that the staffing shortages go beyond a lack of trained individuals.

“There is currently a shortage of EMS instructors, compounding the problem of course availability,“ he said.

The number of EMTs and paramedics varies from department to department, but Grinnell said Harmony ambulance has around 30 staff members, full- and part-time. Portersville has around a dozen, and Karns City has between 12 and 20 at any given time. Pfeifer said there are several EMTs and paramedics staffing Quality EMS at all times, and typically two people respond per ambulance dispatch.

The number varies in departments because they are often subject to high employee turnover, which Grinnell said keeps staff from developing better skills as EMS workers.

“We can't be competitive with the pay. I rarely lose employees to another ambulance service; I lose them to a hospital,” Grinnell said. “I really think the long-term fix is the state needs to change the law, so EMS can also bill tax so we can derive enough income.”

Ambulance services bill clients and their insurance companies for services, which is the main source of income for EMS.

Insurance reimbursements and copays often go unaddressed, according to Pfeifer, but those payments account for a large percentage of their budgets.

“Every time an ambulance responds to a 911 call, the average cost is $750,” Pfeifer said. “Average transport bill is $1,185. Average net amount collected from insurance is 38%.

“If a patient does not have insurance, or refuses to pay their bill, we basically have provided a free service.”

Pfeifer said Medicare and Medicaid also don’t cover much of the cost per ambulance transport. If an ambulance service responds for a hospital transport, the hospital typically pays for the service, but those trips are not common, according to Pfeifer.

Neiper said that in addition to copays coming in low, they also take a long time to arrive.

“You could be waiting three or four months to get a payment,” Neiper said. “Medicare, they pay, but it's nothing. Insurance reimbursement is very, very poor.”

Lauer said Karns City Regional Ambulance Service has resorted to filing lawsuits to get money owed for service, which has been necessary to continue paying employees.

“We will continue to take people to the local magistrate for not paying,” Lauer said. “We have been successful at retaining that money, because the magistrate agrees, they need an ambulance service.”

Pfeifer said Wednesday, July 19, that he and other Quality EMS staff are preparing to speak with administrators of the municipalities the ambulance service covers, in order to obtain sustainable funding.

“We have internally known for the last number of years that emergency medical services nationwide are in serious financial jeopardy,” Pfeifer said. “Due to the rising costs, lack of reimbursement and a critical workforce shortage due to poor industry wages, the effectiveness of our solutions have expired.”

Grinnell said if a funding solution isn’t found soon, EMS agencies could go bankrupt, critically impacting emergency response times. According to Grinnell, ambulance services get few grant opportunities, and they rarely are enough to cover even one day of service.

“It has gone from circumstance where we were happy to break even every year to a situation where we are trying not to lose too much money every year,” Grinnell said. “Reimbursements haven't gone up at all. Harmony doesn't receive any money from municipalities.”

EMS taxes can, by law, only go up to a certain millage — around half a percentage in Pennsylvania, according to Lauer — which could help with funding, but may not sustain EMS agencies in the long-term.

“I think the county itself should put on one mill for EMS,” Lauer said. “There needs to be a sustainable grant program for EMS agencies.”

Some municipalities make annual donations to their covering EMS agency, and even fewer include money budgeted for them. Neiper said the future for EMS agencies is uncertain.

“We want to keep EMS going but I'm not sure how much longer we can going,” Neiper said.