Colorado EMS Sustainability Task Force Update for EMSAC Members

By Sean Caffrey, Crested Butte Fire Protection District
EMSAC delegate to the Colorado EMS Sustainability Task Force

Colorado Senate Bill 22-225 was signed into law on June 1, 2022, representing a significant milestone in the history of Colorado EMS. A major component of the bill established the Colorado Department of Public Health and Environment as the licensing authority for ground ambulance services in Colorado. This was a  change to decades of prior practice where county governments were responsible for ambulance licensing. This portion of the bill will come to a conclusion on July 1 of 2024 when new state-level rules will take effect.

The second part of the SB22-225 created the Colorado EMS Sustainability Task Force to determine the current state of EMS in Colorado and develop recommendations for sustainable EMS systems statewide. The bill further outlined a work plan to take place over 5 years. The task force is comprised of 20 members including a state senator, a state representative, and 18 other members from a variety of aspects of EMS across the state.

While I have the privilege of directly representing EMSAC on the task force, there are a number of EMSAC members from across the state also serving on the task force including Danny Barela, Brandon Daruna, Tim Dienst, Annie Dorchak, James Robinson, Scott Van Slyke, Chris Williams, and Cherilyn Wittler. Our chairman is State Senator Mark Baisley (R–Woodland Park) and the Vice-Chair is State Representative Kyle Brown (D-Boulder).

The Sustainability Task Force’s 5-Year work plan breaks down as follows:

• Year 1
  • Environmental scan describing the current state of the EMS System
  • Comment on the regulatory structure and the role of local government for the EMS system
• Year 2
  • Analyze Date from the Year 1 report
  • Address inequity and disparities in access to EMS
• Year 3
  • Address EMS workforce recruiting and retention
• Year 4
  • Address the financial stability of the EMS system
• Year 5
  • Make recommendations for the long-term sustainability of the EMS system
  • Final report to the legislature

The Year 1 environmental scan was produced in conjunction with SafeTech Solutions and was published in September of 2023 and can be found here. Members of the task force have also been actively involved in the Ground Ambulance Licensing Task Force which has been advising the CDPHE on appropriate ground ambulance licensing rules.

Rules proposed may be difficult to meet

Somewhat unexpectedly, the CDPHE has recommended a rather expansive and burdensome set of regulations despite concerns from stakeholders. There is currently a debate at the SEMTAC level regarding the extent of rules that will be recommended to the Board of Health for adoption that will likely come to a conclusion by the end of the year.

In other year one news, the task force looked at a significant amount of data provided by the Emergency Medical and Trauma Services (EMTS) Branch of CDPHE that led to some interesting findings. Perhaps the most interesting finding is that the vast majority of ambulance services in the state are small with 50% of the services running 600 calls or less. The 75% percentile of services come in at 2,500 calls per year or less with only 5% of services running 10,000 calls per year or more. To paraphrase, this indicates that most of our services are small and their ability to recover costs through ambulance billing is limited with only the smallest fraction able to survive on billing revenue alone. As one would expect, many of these small services primarily rely on volunteer responders with minimal, if any, paid staff.

Looking at other states

Following on this path, the task force looked at recent reports from Maine, Minnesota, New York and Idaho that indicated similar levels of small services unable to adequately recover costs through billing revenue. As part of this process, a financial model was built using a similar approach to Maine and we determined that a small service that deployed only 1 ambulance on a regular basis would likely require $1,050,000 annually to operate with paid staffing and would  only recover about $70,000 in billing revenue leaving a gap of $980,000 annually. Added up across the state and accounting for the various service sizes, there is likely a gap of $332 million.

While this number is large, it is being covered to a large extent by local governments utilizing municipal or special district revenue. A fair amount is also being donated through volunteer labor. Overall, however, this work set the stage for our future work regarding the role of local government and financial sustainability as it is clear that some areas of the state simply don’t have the billing revenue or tax base to support a paid EMS system absent some level of external support.

The task force also spent some time over the summer looking into the role of local government and what “essential service” designation might look like in Colorado. A governance working group spoke with officials from Minnesota, North Carolina, and Tennessee while additional research was conducted offline to determine how essential services approaches worked in Iowa, Arizona, and California.

Overall, the group examined a number of state-level service area designation approaches such as those used in MN, CA and AZ. Local level approaches were also looked at including IA, NC and TN. The group also looked at the key elements of essential service designation that include:

• Assigning a responsible unit of government to ensure EMS is provided,
• Requiring equitable access to EMS services,
• Allowing the responsible government to organize service delivery, and
• Creating a funding mechanism to support EMS service.

After much discussion, the group came to a consensus that a reasonable approach for Colorado would be to assign the responsibility for service delivery to counties. This approach recognizes that counties are really the only level of regional government in Colorado. That being said, it was clearly understood that well over 150 of the 200 services in the state are provided by or contracted with local governments, therefore a partnership approach with counties would be needed.

The governance group will continue work in this area and the funding mechanism will undoubtedly be an ongoing discussion item. We believe our approach, if done well, will have a lot in common with North Carolina, which has arguably one of the most longstanding and sustainable EMS approaches in the country going back over 20 years. Tennessee, which passed its essential service law in the past few years, is taking a similar approach where the state licenses services, counties have the authority to organize and oversee delivery, while local governments, the private sector, and hospitals are the major providers of service. While counties may operate service directly in some instances, their primary responsibility is to ensure the service is available throughout their jurisdiction.

During the course of the task force, we took a deeper look at who was providing ambulance service in Colorado. 

To summarize, about 110 services are some type of special district, with fire districts, ambulance districts and health service districts being the major types. A little less than 20 services are municipal, with fire departments and some separate EMS departments making up that portion.

About 24 services are furnished by county governments or county-owned hospitals. This was interesting as it indicates almost 1/3 of Colorado’s counties are already in the ambulance business to some extent. The private sector, both non-profit and for-profit comprise another 20 percent with the remainder being other models. Interestingly, the largest service in the state, the Denver Health Paramedic Division, is an “other” model as Denver Health is a special subdivision of state government.

Other factors

The task force has done preliminary work on issues with education, recruitment and retention. Danny Barela of the Western RETAC and Region 9 Rep on the EMSAC board of directors has been instrumental in leading that group. Not unsurprisingly, Tim Dienst, EMSAC treasurer has been leading the financial work and those efforts are likely to lead to some legislative activity in 2024 related to surprise billing and appropriate insurance payments in a similar fashion to what Texas has been doing recently. There has also been substantial conversation by the group about the burden of long-distance inter-facility transfers and how that can be best addressed in a comprehensive manner.

Overall, the task force has learned a good bit in year one, and we look forward to our ongoing work. We believe year two will further refine our efforts and we are also hopeful that our equitable access task will also bring in more in-depth conversations around the ongoing role of RETACs to support our system. All task force meetings are open to the public with meeting info available here. We look forward to hearing from you at a meeting soon!