Determining the Costs of an EMS System, and Why It Matters, Part 3
This article is the conclusion of a three-part series examining the cost of modern EMS systems and how these systems can be funded. Part one. Part two.
The 21st Century EMS system
The funding models discussed in previous installments would support the creation of a high-performance EMS system, however, they may not cover the additional costs required to build a 21st-century EMS system, one that goes beyond emergency response to deliver comprehensive, proactive, and integrated healthcare.
A 21st century system would include additional elements such as community paramedics (paramedics with clinical master’s degrees).1,2 These highly trained providers could be strategically deployed for targeted interventions, such as advanced treatment options, chronic disease management, follow-up care, and public health initiatives. To determine those costs, demonstration models would have to be done in systems that employ community paramedics who are paid salaries equivalent to physician assistants and nurse practitioners, and that deploy them to select assignments. The CMS Innovation Center would be an important partner in designing and evaluating these pilot projects.3
Although the U.S. has struggled with articulating EMS educational goals,4,5 other countries have moved to a 21st century EMS system in part by recognizing the critical value of education. There, entry level clinicians have a bachelor’s degree, and advancement to become a manager, educator, researcher, or advanced clinician requires a master’s degree; doctoral degrees are recognized as critically important for further advancement.6,7
Creating the high-performance system in the U.S. would create a foundation for the development of the 21st century system, the community paramedics would improve the care provided to the community and ultimately reduce health care costs more than the costs of implementing the program.8 Creating a stable EMS system would also provide the foundation for building on EMS initiatives focused on injury prevention and improving community health. Those programs too would reduce EMS call volume, relieve overcrowded hospital emergency departments, improve community health, and save the healthcare system more than it costs.9
The 21st system would dramatically improve patient experiences and outcomes though a variety of new initiatives. Paramedics and community paramedics could be more involved in educating the public and being more involved with public health initiatives such as injury prevention.10,11 New technologies such as smart glasses could be evaluated for their ability to improve patient outcomes in EMS systems.12,13 EMS clinicians with doctoral degrees could contribute to significant improvements in EMS education, clinical care guidelines, research and operations.
Ultimately, a bold vision for the future of EMS, a true moonshot, would fully integrate EMS within the broader healthcare and public health ecosystems in a person-centered health system.14 By building on successful initiatives like injury prevention and community paramedicine, we can create a national EMS system that delivers value far beyond emergency response.
Conclusions
Medicare and Medicaid beneficiaries account for approximately 40% of ambulance patients but CMS reimbursement for ambulance service is much less than the cost to provide the service. This underfunding further undermines EMS system financing because other insurers use CMS reimbursement figures to justify underpaying for their ambulance patients.
The analyses presented in this report show that building a high-performance EMS system in the United States may be more financially feasible than previously imagined. Creating such a system would provide the foundation for the development of an integrated EMS system that will assure that all Americans have access to a reliable, efficient, state-of-the-art EMS system. That system would provide 21st century care to Americans that is comparable to the care provided in other advanced countries.
Acknowledgements
The authors extend our appreciation to James T. Kerr (KERR Associates, Inc) for his valuable insights and suggestions.
Disclaimers
There was no funding for this project. The authors have no conflicts of interest.
References
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11. Maguire BJ MP, Gerard DR, Phelps S, Cormier SB, Handal KA, O’Neill BJ. Creating the Emergency Medical Services System of the Future: the role of the EMS Education Agenda. NHTSA EMS Education Agenda 2050. 2024. Available at: https://www.regulations.gov/comment/NHTSA-2023-0037-0101. Accessed: April 12, 2024.
12. Maguire BJ. Seeing the Future: Exploring the impacts of smart glasses on EMS clinical care. Presented at: Vital Signs. New York State, Department of Health. November, 2025.
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