Challenges in Rural & Frontier Mobile Medicine, Part I

By Ed Marasco, MPM, CMTE, EMT-P (Ret.) *


A background of a street with a stethoscope hanging close to viewEmergency Medical Services (EMS) agencies face many challenges in the current environment. In many respects, the EMS experience is a microcosm of the broader healthcare system. There is an abundance of financial, operational, and risk-related challenges at a time when the needs of the communities we serve are growing and changing. Staffing shortages, equipment, and supply shortages, and declining mental health among our team members are among some of the more salient operational difficulties. These headwinds are magnified significantly in rural and frontier communities. The lack of availability of operating resources, the rising costs of providing services, and the lack of adequate revenue sources make the delivery of care and services very difficult. In these two (2) parts series we will endeavor to unpack some of these challenges as they relate specifically to the rural and frontier healthcare environment and explore possible solutions.


The public health emergency exacerbated a problem that was already well-recognized in healthcare delivery circles. Access to quality health care and wellness services has been a challenge for decades. While some progress has been made on some fronts and in some communities, access to services remains an issue for many Americans.

In rural and frontier areas, access issues have been compounded by the fact these populations are often remote and isolated. The sheer logistics of making healthcare services available would be daunting in a more friendly climate. With the recent trends in the closure of rural healthcare facilities, more demand is placed on the remainder of healthcare resources. Often, EMS providers are the last line of defense. Rural providers have seen such things as higher call volume, more ill patients, and reduced availability due to longer transport times. This additional demand has placed more pressure on an already stressed system.


With the closure of rural healthcare facilities, the healthcare needs of the community are growing. The EMS providers may represent the last, best hope for filling this void in many rural and frontier areas. These providers are the one healthcare constant (hopefully) in these communities. In some cases, EMS agencies are forced to make the transition to mobile medicine providers and fill the voids left in the healthcare delivery system. Making the transition from EMS to mobile medicine places more demands on provider teams at a time when they are already overtaxed. Likewise, some of the training and skillsets required for aspects of mobile medicine are different. 

Much work has been done to define Mobile Integrated Health Care and Community Paramedicine in recent years. While reaching a consensus on the definition of these services has been an arduous task, defining the training and qualification of these providers has been even more of a challenge. While much progress has been made, including a certification exam, there is still much debate and many shortfalls on the training side. Rural and frontier providers seeking to expand their scope to meet the needs of the community have many hurdles ahead of them. 


As a faculty member in the University of Pittsburgh Emergency Medicine program, I talk with students each fall about the financial aspects of healthcare. When we evaluate the cost of delivering services, we typically describe the expenses in terms of cost per unit of service delivered. For example, the cost per Emergency Department visit, the cost per inpatient day, or in this case the cost per EMS encounter. 

Like any business, there are fixed costs . . . the cost incurred by an organization prior to the delivery of the first unit of service. In EMS parlance, we often refer to these as “standby” or “readiness” costs. There are also the variable costs for the services . . . what we spend during the course of providing the services. The delivery of health care services, particularly mobile medicine, is what financial people would call a high fixed-cost enterprise. That simply means that readiness costs are most of the expenses. 

Because of the lower population density and larger geographic area to cover, the cost per patient encounter for rural and frontier areas is typically higher than for urban and/or suburban areas. For this reason, the Medicare ambulance fee schedule, developed in 1998-99, included a rural modifier to account for the higher cost per encounter. The challenge is that the current funding mechanism falls short of these costs for well over 75% of patients served. This makes continuing with the current funding mechanism untenable, especially in rural and frontier areas.

The future of rural/frontier EMS and mobile medicine remains a challenge. In our next installment, we will explore some of the possible solutions to the situation.


*Ed Marasco is QMC’s Vice-President of Business Development and a veteran healthcare provider and administrator with over 40 years of experience in emergency medical services, reimbursement, and consulting.

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