RENSSELAER — The Jasper County Commissioners have chosen to re-bid next year's ambulance contract for its next meeting, Dec. 2.
"We had asked for bids a month ago, opened our bids," Commissioner Kendell Culp said earlier this week. "To our surprise, we only had one bid — usually we have four bids — and then dramatically higher than what we had."
This alerted the commissioners to the financial strain gripping local EMS services.
"With the timing of it, I guess, if we would have known this was happening, we'd have backed it up to probably July, so we could build something in our budget," Culp said. "We built a small increase in our budget — nothing like 65 percent of increase. So the county's not in a position to be able to afford the bid, so we have to look for other options."
Culp said local EMS leaders had decided their allotted funds were not adequate to meet their increased needs. These include Phoenix Paramedic Solutions, as well as Wheatfield, Walker and Keener townships.
"If we go off of what we've been doing, that would be a dramatic increase," Culp said of the bid request. "So not only is the Phoenix bid much higher, our subsidies to all the other three townships in the county will be dramatically higher, plus the new population in the new census. It puts the county in a financial position that's just tough to deal with right now."
The commissioners added time to their agenda for local EMS leaders to speak with them about the matter on Monday. Keener Township Trustee Bob Bryan said local ambulance services are struggling to stay afloat.
"Keener has been for years — and actually Wheatfield as well. They are subsidizing their EMS with township funds just to sustain ourselves, to stay above water," he said.
The role of EMS seems to be getting more expensive to run with each passing year.
"You're looking at the payroll end, equipment, replacing equipment," Bryan said. "We're all at that juncture to where we've been going forward throughout the years, but to keep pace with what we need to do to sustain ourselves, obviously more funds would be great."
Bryan added that EMS services might not be paid for one-third of every 1,000 calls.
"Your other third is Medicaid, Medicare," he said. "And then, the other third that you can actually build is your private sector. And, obviously, the insurance companies' job in that is to pay as little as possible."
Phoenix Paramedic Solutions President Nathaniel Metz said Medicaid payments have been slowed, if not outright blocked to some extent.
"We've noticed that traditional Medicaid, in the last two years — especially since they've switched to Southeastrans Inc. as a broker — that their payments have been slower. And there have been more 'rejections,' as they call them — not 'denials,' but 'rejections,'" he said. "It doesn't mean that you actually have a chance to appeal them, which you could do in a 'denial' status."
He said he has been meeting with "a whole bunch" of state officials to discuss it for some time.
"Other services are seeing this all across the state," he said. "I know that I have close to 138 claims that have been unpaid and have aged over a year from Medicaid. And you (can) pair that with the fact that we haven't seen any increase in reimbursement rates from Medicaid since the '70s. I mean, they pay like $86 on a trip. And my cost is way over that."
Metz believes manage care providers are making rules that are intentionally obstructive to needed reimbursements.
"You start talking about manage care providers, who are doing manage care programs for Indiana Medicaid individuals," he said. "They're starting to come out, basically, without any handcuffs and creating rules that, if you ask me, are designed to prevent reimbursement."
This results in a no-win situation.
"We used to be able to make the difference from private insurers," he said. "So we'd pay and charge Medicaid and Medicare rates. But now, private insurers are coming out and just simply saying, 'Hey, if you're not in network, we're not paying you.' They may pay the person, or they may not cover the trip at all. And then, they force you into a network to get money on Medicare rates, and Medicare rates are already below their cost."
In the end, Metz said, local taxes will be footing the bill.
"In my opinion, insurers, particularly private ones — and our government ones are not helping — are pushing EMS to be more heavily supported by local tax funds," he said. "And it's going to hurt rural communities even more."
Metz said he lost $116,000 last year. They are also having a staffing crisis to compete with paramedics and EMT's. He said that, in order to keep staffing up, he raised the hourly rate by $6 per hour over the course of "a couple of months."
"It's going to be tough," he said of the future. "And the only way to sustain the current system is in subsidies."
He said he has heard from a director of Medicaid that transportation benefits may be cut by 1.9 percent next year.
When asked if the providers in Jasper County have agreements to support one another, the representatives present said yes, though they admitted that all agreements are just verbal.
"We definitely work together in helping each other out," said Regional Manager Bob Miller, of Phoenix Paramedics, which recently replaced Prompt Ambulance. "We have not hesitated in providing any of ourselves services."
Keener has two crews at day and one at night. Phoenix has two crews 24/7. Wheatfield Township has one full-time crew.
Bryan said Keener is on track to have roughly 1,150 calls this year.
"Our calls have increased dramatically this year," said Sue Steinke of Walker and Wheatfield Townships. "We don't know what it is. A lot of those are non-payable calls, once again, though. But we are over 200 calls ahead of where we were last year at this point. Two hundred calls on a 600-800 call year is a huge increase. The last seven years, we've been within the 600-call range, and we're already over 800."
Bryan indicated that the local townships can't carry the load all by themselves.
"We're going solely off of billing and then subsidies," he said. "The last two years — we could round it — Keener put right at $90,000 per year to subsidize our EMS. And then, in years prior to that, kind of graduated down the last five years."
Culp agreed with Metz's assessment of the nationwide situation for rural health care.
"(With) rural health care, costs are more expensive and the services are fewer," Culp said. "I mean, that's not just locally. That's everywhere."
He said county leaders and local EMS representatives will have to come up with a solution everyone is happy with in the near future.
"We've got to work together if we're going to come up with a solution to this," he said. "I've never liked the idea of 'Well, if we give you money, then we're going to set these additional rules.' The General Assembly does that all the time with education and all those things. It doesn't make us experts in EMS just because we're providing a subsidy, but I understand that you need more dollars to be able to provide the service."
Culp said an excessive subsidy could result in people becoming involved who are not familiar with the local area.
"We used to have folks that came (from) out of the county," he said. "Nobody knew those people. They didn't know where anybody lived. I mean, it just wasn't a comfortable position for the patient to be in many times. Having a face that they recognize is really important. And you don't necessarily get that if you sub everything out."
The commissioners have two meetings scheduled for December, during which they hope to find a temporary solution everyone can agree on through the bidding process.
"If we only get one bid again, we've got 30 days to figure it out," Culp said.
Commissioner Jim Walstra agreed with him that all parties involved feel somewhat stuck between a rock and a hard place.
"Everybody's in a bind," Walstra said. "I can tell you now, all of us are in a bind. And we've got to work together to get out of this."
Long-term plans may be forged by a special committee that can help the commissioners plan a considerate budget for the oncoming fiscal year.
"We will have this on the December agenda, as far as bid opening," Culp said. "And then, we do have a second meeting in December. So it doesn't give us a lot of time, but we know long-term we probably have to get a committee together, a working group, and be thinking to 2021."