I am enjoying the ongoing discussions about these lectures. “Financing EMS” for Fall 2025 is sourced from the most recent information provided by the PWW Advisory Group, AimHi, NAEMT, Centers for Medicare & Medicaid Services (CMS), and the American Ambulance Association.
This week’s ask:
- Is there a newer ambulance replacement guideline than Dan Fellow’s April 2016 EMS World article?
You can reply below or email michaelward@isu.edu.
Background to these lecture topics
EMS financing and vehicle/durable medical equipment procurement are volatile topics due to the pandemic and the DOGE-driven federal reorganization. I anticipate that both of these lectures will require major updates for the Fall 2026 semester.
11: Financing EMS
The 3300 lecture starts with review of the July 22, 2025 “The true cost of a 911 call: Breaking down EMS economics” by Matt Zavadsky pubished by ems1.com.
This replaces the 2019 NAEMT/AimHi webinar “How EMS is Financed” presented by Chip Decker and Matt Zavadsky. They describe the sources of revenue:
- Fees For Service
- Tax Subsidy
- Other:
- Grants
- Special Assessments
- such as a Tax Levy
- Ground Emergency Medical Transport (GEMT) program
- Subscriptions
A review of the payor types and their payment performance.:
- Medicare
- Medicaid
- Private Pay
- Commercial Insurance
- Other
Fees For Service: Deeper Dive
Describe how Centers for Medicare & Medicaid Services (CMS) differentiates Suppliers and Providers. Describe how ambulance services is identified as a supplier and its reimbursement implications. Briefly discuss the unique reimbursement opportunity for hospital-based ambulance services.
Scan the decades of documentation showing that the insurance reimbursement fails to cover the direct cost of an ambulance transport. Look at the additional “cost of preparation” for 9-1-1 services. Review February 17, 2025, PWW Advisory Group “Quantifying the gap between expenses and revenue for EMS services: Takeaways from the First CMS Data Collection Report on Ambulance Services to enhance service levels and reduce costs of service delivery” [https://www.ems1.com/ems-trend-report/quantifying-the-gap-between-expenses-and-revenue-for-ems-services]. Their conclusion:
The average revenue shortfall for all ambulance suppliers is 57% for every transport performed.
Tax Levies: Deeper Dive
Doing a deeper dive into tax levies. Start with describing the 1997 failure of the Seattle/King County Medic One Foundation tax levy vote. Review the narrow post-pandemic failure of many tax levy proposals for emergency ambulance service. Describe the efforts it took Canyon County Paramedics, Idaho, to get a tax levy passed in 2025 after two failures in 2024.
Ground Emergency Medical Transport (GEMT) Program: Deeper Dive
A federally funded state supplement payment program that is likely to be reduced or eliminated due to the current government reorganization. Review the March 11, 2025 PWW Advisory Group assessment of Texas GEMT and its national implications.
Fire Department takeover: Overstated revenue, understated costs, and ignorance of health care insurance reimbursement practices
Ambulance billing is complex. Many hospital-based EMS systems contract out for ambulance billing even when they do the rest of their medical billing in-house. Several of the largest fire-based ambulance services have faced significant penalties from CMS/US Justice Department due to improper billing practices. We will examine the financial issues of a fire department takeover of ambulance services, with 2025 examples from Sonoma County, California, and Evansville, Indiana.
Review the 2023 financial profile of AMR’s Multnomah County, Oregon, operations in light of a years-long fight over paramedic ambulance staffing. Discuss the failed effort of Santa Barbara County Fire Department’s effort to take over ambulance service from AMR in 2025 – and what to do with 35 never used fire department ambulances.
Wrap up lecture showing the PWW Advisory Group/NAEMT The “One Big Beautiful Bill Act” Potential Impacts on EMS: A Wake-Up Call for Financial Sustainability “living document” to highlight the potential revenue, human resources and tax implications of the OBBBA on the EMS system and EMS employees.
Required Readings/viewings
Zavadsky, M. (2025 July 22) The true cost of a 911 call: Breaking down EMS economics. ems1.com https://www.ems1.com/ems-management/the-true-cost-of-a-911-call-breaking-down-ems-economics
Reference: 2019 “Follow The Money: How EMS is Financed” NAEMT/AimHi [1 hour 3:34 minutes]
PWW Advisory Group. (2025 March 11). Analysis of 2023 vs. 2022 Texas GEMT Funding Distribution. https://aimhi.mobi/news/13473236
PWW Advisory Group and NAEMT (2025 July 17) Table of Major Provisions In HR1 That May Impact EMS. https://aimhi.mobi/news/13522232
Welsch, Nick.(2025 July 23) Santa Barbara County Fire Chief Announces Retirement: Hartwig Fought to Take Over AMR Ambulance Monopoly. Santa Barbara Independent. https://www.independent.com/2025/07/23/santa-barbara-county-fire-chief-announces-retirement/
12: Ambulance/Durable Medical Equipment Procurement
The 3300 lecture describes the procurement process for vehicles and durable medical equipment, highlighting the parameters that differentiate a Request For Proposal versus a Purchase Order.
Identify the special situation of ambulances and durable medical equipment, such as the KKK-A-1822 ambulance classification scheme and Federal Food and Drug Administration (FDA) certification of durable medical equipment operating in an out-of-hospital environment.
Brief review of our current supply chain position in the post-pandemic marketplace.
When To Replace An Ambulance
Review Ron Fellow’s description about the Richmond Ambulance Authority (RAA) fleet replacement goals:
- Maintain a fleet size capable to 133% of peak-of-day operations
- Replace after 150,000 to 250,000 miles
- Replace after 4 to 7 years
Describe the process and value of remounting Type 1 and Type 3 ambulance boxes on new trucks.
Individual Assignment: Construct a 3 year ambulance replacement plan for BengalCare Mobile Health. You inherent a fleet of 16 ambulances from Mercy 911, Mercy Transport, and Mount Pleasant Fire Department. Using Ron Fellow’s RAA guidelines, your subject matter expert provides a spreadsheet analyzing all ambulances.
BengalCare Mobile Health peak deployment is 12 ambulances, will need 16 ambulances to get to 133% peak-of-day. Of the inherited fleet of 16, only 11 are roadworthy. Using a state cooperative purchasing program price guide for new ambulance purchases and remounts, identify how you will update the fleet with the $375,000 budgeted for new/remounted ambulances each year?
Required Readings/viewings
“Wheeled Coach Walk-Around, FDIC 2024” (5:02 minutes)
Featured picture: Penn Township Ambulance Association. May 8, 2024. Today, Chief Grant inspected Unit 228 at the REV Group, Inc. remount factory. Progress is on track for expected completion at the end of the month. The remount process avoids about $50,000 of expense versus purchasing a new modular box construction.