Dylan Ferguson, the director of the Pennsylvania Department of Health, Emergency, and Medical Services, was the featured guest speaker at a town hall-style meeting in Kennett Square to discuss EMS services, how they are delivered, and potential changes and challenges to the delivery systems in the future.

The meeting, which was held at the Red Clay Room in Kennett Square, attracted a large crowd of local residents. EMS and fire services have been hot topics of discussion in the last year, as a committee comprised of representatives from Kennett Square and the surrounding municipalities has looked at fire and EMS services in the region.

At the onset of the town hall, Kennett Square Mayor Matt Fetick, who helped organize the meeting, explained that the goal for the night was to provide useful information about EMS services in general, and the town hall was not meant for in-depth discussion about EMS services in the Kennett Square region.

“It's really about the EMS system, how is it delivered, what it looks like,” Fetick explained. He emphasized that Ferguson was invited to offer some insights into how EMS services are offered throughout the state, and he would not be in a position to offer any sort of recommendation on how the Kennett Square region should have EMS services provided in the future.

Early in his presentation, Ferguson also touched on this point, saying that it was really up to a local community to determine how to meet its needs for EMS services.

“Localities have the right to make their own decisions,” Ferguson explained. He outlined the three function areas of the Bureau of EMS, which includes education; data and quality improvement; and preparedness and response.

For education, the Bureau of EMS services focuses on the areas of accreditation of educational institutes, initial certification education, examination processes, and continuing education. For date and quality improvement, the bureau focuses on the area of clinical and regulatory compliance, data collection, quality improvement processes, and EMS agency licensure. For preparedness and response, the bureau focuses on emergency response functions as it relates to disaster response, special events planning, and communications.

Next, Ferguson explained that there are 13 regional EMS councils across Pennsylvania that act as agents of the department. These councils do a lot of work, including conducting licensure inspections, administering certification exams, providing technical assistance to agencies to comply with EMS Systems Act, and investigating complaints. One of the 13 regional EMS councils oversees Chester County.

There are 1,258 EMS agencies across the state. Ferguson explained that there is a wide range to those services. Approximately 70 percent of the 1,258 EMS agencies are Quick Response Service or Basic Life Support—which is to say a vast majority of the EMS agencies are offering the basic care that patients need until they can receive more advanced treatments. The Quick Response Service is designed to provide emergency medical care prior to the arrival of a transport capable EMS vehicle. The Basic Life Support ambulance provides what the name suggests—basic life support care to the sick and injured. It is staffed, at a minimum, with one Emergency Medical Technician (EMT).

There are also Intermediate Advanced Life Support and Advanced Life Support, which both provide more advanced services than what is possible through Quick Response Service or Basic Life Support. An Intermediate Advanced Life Support ambulance is staffed with the minimum of one paramedic. There are also Critical Care Transports and Air Ambulances for more specific, and advanced, medical needs. Critical Care Transport is only for transporting people between facilities, and is not used for 911 calls. The air ambulance is designed for the scene of the emergency or for 911 calls where critical care is needed.

Ferguson also talked about the people who are on the front lines of providing quality emergency medical care. He explained that there are 42,296 certified care providers in the various EMS systems throughout Pennsylvania. Of those, 29,462 are EMTs. They have all completed at least 180 hours of training.

There are 245 advanced EMTs currently certified in Pa. They have the same training as EMTs, but then have an additional 180 hours of training. The state has 6,948 paramedics who have received 1,000 hours of training. They are highly skilled at delivering care during an emergency.

“Paramedic training is extremely grueling,” Ferguson explained, noting that they spend many hundreds of hours learning in the field while they are completing their training.

There are 1,210 pre-hospital RNs, which represents the highest level of training for people who would be responding to emergency calls on a regular basis. Additionally, there are 3,256 emergency medical responders, who are trained to get the care started until more advanced medical personnel can arrive to transport patients to a hospital.

Ferguson said that the duties and training for EMTs has evolved greatly since they were first widely utilized in Pennsylvania in the 1970s. Back then, EMTs would have only provided very basic care. They are now trained to handle many different issues on the scene and en route to a medical facility.

“Today, our EMTs are tasked with providing more medical care than at any time in history,” Ferguson explained.

While that higher level of care is unquestionably a good thing, it doesn’t come without costs. Today, EMS agencies are doing more with fewer resources. It’s up to the local communities to determine how much they can afford to spend on EMS services. That can be very challenging.

Ferguson explained that it's about getting the right care to the right person at the right time.

“Every single component of the system is equally important,” he explained. “We truly have to work together as a team to ensure that everyone is taken care of.”

Ferguson talked about how call volumes are increasing to take care of an aging population.

“The simple fact is EMS providers see a 7-percent increase in calls every year,” he said. “That is a trend that we expect to see continue.”

Many of the EMS agencies in Pennsylvania are reliant on volunteers to fully staff the vehicles.

“There are portions of this Commonwealth, and portions of this country, where volunteerism still runs deep,” Ferguson explained. But in many areas, the number of volunteers is decreasing, forcing many communities to boost spending to maintain the level of coverage.

Ferguson said that there are many factors that contribute to the declining number of volunteers—for starters, there are many more two-income families, and people are working harder and for longer hours. There are also many more activities for children to enjoy, so moms and dads are more often traveling to take their children to baseball tournaments or dance classes or robotics events. People have more demands placed on their time so they can’t volunteer as often.

At the same time, to ensure a high quality of care, first responders are being asked to undertake more and more training. There’s nothing wrong with high expectations for care, Ferguson said, but it does make it more difficult to attract and maintain volunteers, especially at a time when people have so many other obligations.

“The expectation is that someone who is highly trained and competent will show up and provide whatever you need to feel better,” Ferguson explained, but the additional training places more demands on the volunteers.

Ferguson also briefly talked about EMS billing, and the payments that EMS agencies receive for services. He explained that many people believe that EMS agencies bill and receive full payment for all services. The reality is that, on average, 50 percent to 70 percent of all reimbursements come from Medicare, government-contracted MCO's and Medicaid. There are fees for services for these programs that have set payment rates, regardless of what it costs the EMS provider. It may cost an ambulance division more to go out and respond to a call than it will receive in reimbursements from Medicare, government contracted MCO's and Medicaid. Ferguson pointed out that no business model will work if the costs to provide a service are greater than the payment for those services.

Sometimes, an EMS agency won’t be reimbursed at all for a call. Currently, if someone calls 911 and the first responders are able to resolve the issue without transporting the patient, the ambulance division may not be reimbursed. State lawmakers are looking at “treat-no-transport” legislation that would allow ambulance divisions to be reimbursed.

The state also increased funding for the Medicaid fee schedule.

Emphasizing the local aspect of EMS services, Ferguson said that, moving forward, EMS agencies and municipalities must communicate effectively to understand each others’ needs. Municipalities must also consider cooperative agreements with other municipalities and agencies.

Ferguson also said that, in the future, there could be an increase in “paramedicine” where EMS providers will be offering services to help people address issues before they turn into an emergency situation that requires health care with the highest costs.

“We can take a serious look as communities, as EMS providers, as agencies, to think outside the box,” Ferguson said.

During a brief Q & A period, one Kennett Square resident shared a story that illustrated the importance of quality EMS services. The man explained that his wife fell in the home and broke her neck. There was a quick response from first-responders. Today, she is doing much better, in part because of the prompt and professional treatment. The man said that they would be willing to pay higher taxes to ensure that that kind of service could be maintained.

Ferguson said that a variety of factors need to be evaluated when a local community makes decisions about EMS services.

In the coming months, there will be conversations taking place in the Kennett Square region. The presentation by Ferguson provided some valuable information for officials and residents to consider.

“Right now, there is not a specific path forward,” Fetick emphasized. “This is the beginning of the conversation, not the end.”

Elements of a viable EMS system

The Kennett Regional Fire and EMS Commission has been tasked with studying how fire and EMS services are provided—and paid for—by Kennett Square Borough, Kennett Township, East Marlborough Township, Newlin Township, Pennsbury Township, and Pocopson Township. In 2017, those six municipalities agreed to form a commission to look at how fire and EMS services are provided and paid for in the region, with the simultaneous goals of optimizing services for residents while also identifying the most efficient way to pay for those services.

During his presentation, Dylan Ferguson, the director of the Pennsylvania Department of Health, Emergency, and Medical Services, outlined the elements of a viable EMS system. This is of particular interest for residents in the Kennett Square region because decisions about how to maintain viable EMS divisions (and fire companies) are looming.

So what are the elements of a viable EMS system?

Ferguson outlined them:

~ Adequate call volume:

There must be a sufficient billable call volume to support the level of service.

~ Cost of readiness:

Being able to sustain and absorb the costs of 24-hour and year-round readiness.

~ Effective administration of the agency:

Management of human resources, operations, compliance, and billing.

~ Adequate reimbursement for services provided:

Just as there must be adequate billable call volume, the reimbursements at the EMS divisions receive for their services must be sufficient to cover the costs of providing those services.