Emergency Medical Services (EMS): A Look at Disparities in Funding and Outcomes

Overview

Limited EMS funding may affect nationwide EMS quality. The scarcity of nationwide EMS data makes studying disparities challenging; however, studies have found disparities in EMS services based on geography (urbanicity), income, sex, and race.123 Using data from California's local EMS agency reports, we conducted a limited case study that illustrates geographic disparities in EMS revenue, spending, and cardiovascular (CV)-related quality indicators.

EMS disparities and service-related challenges within the United States

Nationwide EMS challenges

Despite widespread popular support for additional EMS funding,4 limited EMS resources contribute to service-related challenges throughout the nation. Recruiting qualified emergency medical technicians (EMTs) can be difficult because of:

• Low salaries (national average: $34,320)
• High turnover
• Lack of racial equity among staff (in 2019, 86.6% of EMTs were White)
• Insufficient operations support:
  • Reports of ambulances held together with duct tape
  • Reports of bake sales to raise money for fuel
• Little recognition of EMS role in public health
• Poor opportunities for staff training5

Disparities in funding for state EMS offices

Overall, limited EMS support is provided to state EMS offices. But funding levels vary greatly:

• State funding
  • Three states spend more than $10 per person on funding for EMS offices.
  • Three additional states spend more than $2 per capita on EMS office funding.
  • Twenty states spend between $0.50 and $2 per capita on funding of EMS offices.
  • Twenty-four states and the District of Columbia spend less than $0.50 per capita on EMS funding or declined to respond to the survey question.67
• Federal funding
  • Four states received more than $1 per capita in federal funding for EMS offices.
  • Twenty-nine states received less than $0.10 per capita in federal funding for EMS offices or declined to respond to the survey question.67

This variation in state and federal resources may contribute to disparities in the quality and availability of EMS.

Geographic disparities in EMS

Geographic disparities in EMS based on urbanicity have been identified nationwide. Specifically, rural areas have:

• Greater reliance on volunteers and/or part-time staff
• Paramedics with basic, rather than advanced, life support certification
• EMS paramedics who are less likely to receive prearrival instructions
• Heavier reliance on fee-for-service funding
• Longer prehospital response and transport times
• EMS systems that lack consistent medical oversight, which affects outcomes
• Higher rates of patients who require EMS transport
• Substantially higher costs for pregnant women with preterm labor189

Income, sex, and racial disparities in the provision of EMS

Multiple studies have also identified disparities in EMS based on income, sex, and race.

• Income-based disparities in EMS include the following:
  • EMS response times were 10% longer in lower-income neighborhoods.
  • EMS responses were more likely to meet 8- and 15-minute cutoffs in high-income areas.2
• Sex or gender-based disparities in EMS include the following:
  • Less accurate identification of stroke in women
  • Longer average response times when responding to women
  • Lower likelihood of receiving recommended care for women with chest pain or out-of-hospital cardiac arrest310111213
• Race or ethnicity-based disparities in EMS include the following:
  • Less accurate recognition of stroke in racial minorities
  • Lower likelihood of assessment for pain in Hispanic and Asian patients
  • Lower likelihood of treatment for pain in Black, Hispanic, and Asian patients314

California case study: disparities in EMS

Race-based and sex-based disparities in EMS care and outcomes have also been found in studies focused exclusively on California.

• Crowding in emergency departments disproportionately affects racial and ethnic minority groups.151617
• Hospitals that serve predominately Black populations:
  • Encounter ambulance diversion at higher rates
  • Have fewer available resources
  • Have less access to cardiac technology151617
• Black and Hispanic patients suffering a myocardial infarction have:
  • Lower rates of revascularization
  • Longer times between arrival at a hospital and administration of treatment (longer door-to-balloon and door-to-needle times)
  • Higher mortality rates for ST-segment elevation myocardial infarction (STEMI)
  • Fewer benefits from regionalization, a program designed to more quickly route STEMI patients to facilities providing recommended treatments18
• Stroke recognition is less accurate for:
  • Women
  • People from racial and ethnic minority groups3

EMS spending and revenue for five local EMS agencies (LEMSAs) in California

Disparities in EMS funding and quality can be analyzed in more detail through a case study that examined local EMS agencies (LEMSAs). To facilitate analysis of local data, the project team selected five LEMSAs that cover 11 counties.A The five selected LEMSAs—Alameda, Kern, Los Angeles, Mountain Valley, and North Coast— include three single-county LEMSAs and two multicounty LEMSAs. They were selected based on diversity in socioeconomic status, racial/ethnic composition, and rural/urban territory. For a detailed description of our methodology, see Appendix: Detailed Methodology and Data Sources.

Figure 1 shows the sources of available funds. There are three local funding sources listed: the Maddy EMS Fund, EMS levies, and all other local funding sources. While there is supplemental state funding available for rural LEMSAs (especially multi-county rural LEMSAs), the most LEMSA revenue comes from local resources. And urban LEMSAs have substantially more per capita revenue than rural LEMSAs.

Figure 2 shows disparities in EMS expenditures between the LEMSAs studied. Per capita spending ranges from $2.16 per person in Mountain Valley to $18.72 per person in Alameda. The three rural LEMSAs—Kern, Mountain Valley, and North Coast—spent substantially less per capita than the urban LEMSAs. And Alameda spent substantially more than any other LEMSA, likely because of funds available from its EMS levy.

EMS core quality indicators for five local EMS agencies in California

Understanding the overall quality of EMS care is helpful, and the EMS System Core Quality Measures Project gauges the quality of EMS care provided within each LEMSA. As part of this project, each local EMS agency (LEMSA) tracks metrics (core quality indicators) related to best practices in EMS care, such as administration of aspirin to STEMI patients or prenotification to hospitals before stroke or STEMI patients are dropped off.19

The project was created to make prehospital data more accurate and accessible for public, policy, academic, and research purposes. It is also meant to highlight opportunities to evaluate and improve the quality of patient care delivered within an EMS system. It uses quality indicators developed by the National Quality Forum related to performance of EMS systems, recommended treatments, and transport to appropriate facilities.19

In our case study, we examined each LEMSA's core quality metrics that relate to documented best practices in treatment of stroke and STEMI patients and found that:

• The two urban LEMSAs, Alameda and Los Angeles:
  • Have at least one stroke or STEMI-related indicator in the top quintile
  • Have the highest EMS revenue and spending levels
• The three rural LEMSAs, Kern, Mountain Valley, and North Coast:
  • Have no stroke or STEMI-related core quality indicators in the highest quintile
  • Have at least one core quality indicator in the lowest quintile
  • Have substantially lower EMS revenue and spending levels than the urban LEMSAs
• Though Alameda spends substantially more per person on EMS than Los Angeles, Los Angeles reports more core quality indicators in the highest quintile.

Table 1. STEMI-Related EMS Core Quality Indicators for Five LEMSAs and Statewide Median, 201919

Table 2. Stroke-Related EMS Core Quality Indicators for Five LEMSAs and Statewide Median, 2019

* LEMSA's population in the highest quintile (20%) of LEMSAs that reported indicator.
† LEMSA's population in the lowest quintile (20%) of LEMSAs that reported indicator.

Conclusions and implications

Nationwide studies of EMS are limited, but they illustrate disparities based upon income, sex, and geography.12891011121314 In addition, multiple California-based studies show disparities in the quality of EMS by race and ethnicity, and one California-based study also shows disparities based on sex.315161718

This case study identified large disparities in EMS revenue and spending between urban and rural LEMSAs. This is consistent with nationwide studies, which suggest that EMS in urban areas tend to have better funding and be of higher quality.4 The case study also identified the sources of funding streams for EMS in California (see Emergency Medical Services: Local Authority, Funding, Organization, and Management for additional details). Though limited state funding is available for multicounty rural LEMSAs, and limited federal grant funding may also be available, most of the funding for EMS comes from local governments, which raise funds primarily through taxation. Addressing funding disparities may reduce geographic disparities in EMS outcomes.

Though this case study focuses on 11 California counties, there is evidence of EMS disparities throughout the nation. Some of the findings may be helpful to policymakers in other California counties or other states who are interested in addressing EMS disparities.

Glossary

1. Ambulance diversion: redirection of ambulances away from hospitals because of a lack of available beds.20
2. Cardiac care regionalization: As used here, regionalization is based on recommendations from the American College of Cardiology and the American Heart Association, which require regionalized STEMI networks to "have an emergency medical system that instructs prehospital transport to directly transport patients with STEMI to facilities that offer emergency PCI, bypassing hospitals that do not offer it, and have interhospital transfer protocols specifically for patients with STEMI."18
3. EMS levy: a property tax imposed specifically for the funding of EMS.21 Note that in California, EMS levies are often referred to as special taxes for EMS.22
4. EMS System Core Quality Measures Project: The EMS System Core Quality Measures Project measures the quality of EMS care provided within each LEMSA. These measures are defined as "a set of standardized performance measures intended to examine an EMS system or the treatment of an identified patient condition."23 The California Emergency Medical Services Authority (EMSA) established the project in 2012 with grant funding from the California Health Care Foundation. The California EMSA preliminarily derived the measures from projects completed by the National Highway Traffic Safety Administration (NHTSA), the National Quality Forum, and the National Association of State EMS Officials (NASEMSO) EMS Compass Project. A task force that includes California EMSA representatives and other EMS stakeholders (the Core Quality Measures Workgroup) meets twice a year to discuss and refine the measures. In 2019, the National EMS Quality Alliance published a set of measures (updated in 2021) which we have listed below. Because this primer includes local EMS agency reports from 2019, we use Core Quality Indicator data from the same year.23
5. Maddy EMS Fund: a fund established to provide critical resources for the delivery of emergency medical care to the uninsured. Funds are managed at the county level, with funding generated through the assessment of an additional penalty of $2 for every $10 collected in fines, penalties, and forfeitures for criminal offenses. Revenue is distributed for county administration cost, for reimbursement to physicians/surgeons and hospitals for the cost of uncompensated care, and for discretionary EMS purposes. As of 2019, 51 of the 58 counties in California had established a Maddy EMS Fund.24
6. Other local funding sources: All revenue raised at the local level, excluding specific EMS levies and moneys from the Maddy EMS Fund. It includes transfers from the United States and state governments.
7. Revascularization: "a surgical procedure for the provision of a new, additional, or augmented blood supply to a body part or organ."25
8. ST-elevation myocardial infarction (STEMI): a type of severe heart attack that involves the death of the heart muscle and total arterial blockage.26