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


Emergency 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. These headwinds are magnified significantly in rural and frontier communities. In this second part of the two (2) part series, we will explore possible solutions.

A background of a street with a stethoscope hanging close to view




  • Technology

As in many businesses, exploring the use of technology to enhance services and/or drive efficiencies is a concept that dates back to the previous century. EMS has benefitted from such technological advances over the years. The emergence of telehealth technology during the recent public health emergency represents another opportunity for EMS and mobile medicine, especially in rural and frontier areas. Using telehealth capabilities could support a more effective triage mechanism to moderate the demand for these valuable resources. We know that the number of emergency department visits during the pandemic was reduced drastically with the availability of telehealth resources. It could be used to augment the delivery of mobile-integrated healthcare in a more effective way by enhancing the services that can be delivered in the home (vs. requiring transport). Telehealth may also be a tremendous tool to enhance the capability of rural EMS and rural hospitals in an effort to reduce total mission time and the length of EMS transports. There are many more possibilities beyond the application of this single technology. As a community, we must strive consistently to deploy technology that will allow us to better serve our patients and communities.

  • Regionalization

EMS is predominantly locally based in the United States, which makes regional coordination and cooperation more challenging. However, the realities of community needs and the economic framework of EMS in rural and frontier areas make regionalization a must for long-term success. It is more efficient to cover a broad geographic area while sharing the fixed cost of EMS. Sharing such things as back-office functions, training, and purchasing power may help to reduce the cost per encounter. There are certainly terrain and geopolitical barriers that need to be addressed in any regionalization effort; however, the opportunity for improvement appears to be significant on this front. We need to think about EMS and mobile medicine more in regional terms than in local fiefdoms.

  • Funding

Financing rural and frontier EMS and mobile medicine is challenging because of greater service needs, longer total mission times, longer miles traveled, and lower call volume. The primary funding mechanism for EMS remains third-party reimbursement from healthcare payors. This compensation is still, primarily, in a fee-for-service format. There needs to be a shift in financing from this reliance on third-party payors toward a more stable funding source to cover the fixed cost of EMS and mobile medicine. Government funding at the local/regional level has been inadequate. While federal funding in the early years of EMS may have been adequate, that funding has declined steadily over the last 50 years. EMS should be viewed, from a funding perspective, just as our colleagues in the other public safety disciplines (police and fire) are.  There should be a line-item funding for EMS that recognizes and compensates the agencies for readiness costs. It is my firm belief and hope that the ongoing Medicare Cost Data Reporting for Ambulance Services data will cement the idea that funding is currently inadequate, and we must find a better answer.

  • Where does EMS belong?

One final point about EMS that must be addressed is the “Federal home” for EMS. Our roots are in the Department of Transportation and those origins made sense in the 1970s. However, EMS and mobile medicine have evolved beyond that era . . . we are more medicine than transport these days and it is likely this maturation will continue. EMS should have a new home in the Federal government and that home should be reflective of our primary attributes today and into the future.



The delivery of EMS and mobile medical care in rural and frontier settings is challenging, but we have many more tools in our toolbox today to mitigate these challenges. We need a more comprehensive approach to EMS and mobile medicine, especially in rural and frontier settings.

For more information about these issues, please take some time to review the report by the National Advisory Committee on Rural Health and Human Services entitled “Access to Emergency Medical Services in Rural Communities” which was issued in November of 2022. It is an informed and thoughtful review of the challenges.


*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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