What Does it Cost to Maintain a Rural Ambulance Service? Yvonne Jonk, PhD1; Gary Wingrove, FACPE2,3; Nikiah Nudell, MS, NRP2; Kevin McGinnis, MPS, EMT-P4,6; Thomas Nehring, BS5,6; Gary Hart, PhD1 1Department of Population Health, University of North Dakota School of Medicine & Health Sciences, Grand Forks, ND; 2The Paramedic Foundation, St. Cloud, MN; 3Mayo Clinic Medical Transport, Rochester, MN; 4North East Mobile Health Services, Scarborough, ME; 5North Dakota Department of Health, Division of EMS and Trauma, Bismarck, ND; 6National Association of State EMS Officials, Falls Church, VA Background Table 2. Costs Associated with Ambulance Service Tiers: Start-up Fixed Costs, Annual Depreciation, Variable Costs, Administrative Costs Recent trends in rural hospital closures have heightened concerns over preserving access to emergent health services for rural residents. Potential solutions include setting up freestanding emergency departments or primary care clinics with ambulance services. Although previous studies have developed toolkits for estimating costs, no studies have addressed the actual costs of running ambulance services. This paper provides estimates of the fixed, variable, depreciation, and administrative costs for three population-based service tiers.   Tier 1 (<800 Responses/Yr) Tier 2 (800-1499 Responses/Yr) Tier 3 (1500-2200 Responses/Yr) Start-up Costs Annual Costs Fixed Costs Depreciation Ambulance and Medical Equipment * 1 Primary Ambulance 2 Primary Ambulances 3 Primary Ambulances Primary Ambulance and Equipment 191,164 19,116 382,328 38,233 573,492 57,349 Secondary Ambulance Back-up 166,164 16,616 Additional Ambulance Back-up 141,164 14,116 Chief/Supervisor Unit 50,000 5,000 Total Vehicle & Equipment Costs 548,492 54,849 739,656 73,966 930,820 93,082 Building ** 1,500,000 Communications Equipment *** 127,188 23,122 152,068 27,819 176,948 32,516 Variable Costs Ambulance Crews - Salary & Benefits (n-24x7, 1-on-call, 1-transport; 1-chief) 1-24x7 crew 629,614 2-24x7 crews 1,042,385 3-24x7 crews 1,455,156 Training (Initial & Re-certification, CE) 11,319 19,644 26,559 Total Fixed & Annual Costs, Respectively 2,175,680 768,904 2,391,724 1,213,813 2,607,768 1,657,313 Administrative Costs Other Administrative (9% of budget) 69,201 109,243 149,158 Grand Total Annual Budget (Depr + Var + Admin) 838,105 1,323,057 1,806,471 Methodology Costs estimated by a national panel of ambulance service policy and operations experts: Gary Wingrove, Government Affairs Specialist for Mayo Clinic Medical Transport, and President and Chief Innovation Officer of The Paramedic Foundation; Tom Nehring, Director of the North Dakota Department of Health, Division of EMS and Trauma, current National Association of State EMS Officials (NASEMSO) Rural EMS Committee Chair and Co-Chair of the Joint Committee on Rural Emergency Care (JCREC); Nick Nudell, MS, NRP, chief data officer of The Paramedic Foundation; Kevin McGinnis MPS, Paramedic, Program Manager, Community Paramedicine - Mobile Integrated Healthcare, and Rural Emergency Care, NASEMSO; Teryl Eisinger, Director, National Organization of State Offices of Rural Health (NOSORH); Lynette Dickson, MS, RD, LRD, Associate Director, Center for Rural Health and member of the ND EMS Advisory Committee. Three levels, or tiers, of service reflecting the service area’s population density were considered. A minimum access standard was defined as serving a maximum 25-mile radius (ie 2,000 square miles) and consists of one full-time staffed ambulance, with a second unit on-call supported by a chief. * Straight-line depreciation over 10 years was used for ambulance and medical equipment ** Straight-line depreciation over 30 years was used for buildings *** Weighted straight-line depreciation was used for communications equipment: radios (7 years), cell phones (3 years), laptops (3 years) Table 3. Breakeven Analyses: Costs per Response*   Tier 1 (<800 Responses/Yr) Tier 2 (800-1499 Responses/Yr) Tier 3 (1500-2200 Responses/Yr) Range of Responses Minimum Maximum 799 800 1499 1500 2200 Grand Total Annual Budget $838,105 $1,336,577 $1,835,048 Distribution of Responses Annual No. of Responses Cost per Response 25 $33,524 50 $16,762 $ 1,671 $ 1,223 100 $ 8,381 850 $ 1,572 1550 $ 1,184 150 $ 5,587 900 $ 1,485 1600 $ 1,147 200 $ 4,191 950 $ 1,407 1650 $ 1,112 250 $ 3,352 1000 $ 1,337 1700 $ 1,079 300 $ 2,794 1050 $ 1,273 1750 $ 1,049 350 $ 2,395 1100 $ 1,215 1800 $ 1,019 400 $ 2,095 1150 $ 1,162 1850 $ 992 450 $ 1,862 1200 $ 1,114 1900 $ 966 500 $ 1,676 1250 $ 1,069 1950 $ 941 550 $ 1,524 1300 $ 1,028 2000 $ 918 600 $ 1,397 1350 $ 990 2050 $ 895 650 $ 1,289 1400 $ 955 2100 $ 874 700 $ 1,197 1450 $ 922 2150 $ 854 750 $ 1,117 $ 892 $ 834 Funding: This project was funded by the Federal Office of Rural Health Policy within the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1CRH24742 entitled “Rural Health Research Grant Program Cooperative Agreement”. This information or content and conclusions are those of the author(s) and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. Results Table 1. Fixed, Variable and Administrative Costs for the Ambulance Minimum Access Standard Expense Category Costs Assumptions Start-up Fixed Costs   Ambulance and Equipment Costs $191,164  Vehicle $115, 759 Defibrillator $38,000 Stretcher $16,000 Mobile radio $6,808 All other supplies $14,597 Secondary Ambulance Back-up 166,164 Additional Ambulance Back-up 141,164 Chief/Supervisor Unit 50,000 Building 1,500,000 Communications Equipment 127,188 Base station radio $35,108  Portable radios include 2 units for duty crew, 1 unit for chief, 4 units standing by at the station for activated back up, and one spare. Seven portable radios $66,080 Cell phones, service for each of 3 vehicles $10,000 Ruggedized laptops for ePCR per vehicle ePCR = electronic Patient Care Report Total Start-up Fixed Costs $2,175,680 Annual Variable Costs Annual Employee Salaries $629,613 On duty crew $317,462 2 people, 24 hours a day; $18.12/hr=70% of $23.56 volunteer time cost On duty crew benefits $95,309 30% of $23.56 volunteer time cost “On-call” crew on pager $127,020 2 people, federal min wage of $7.25/hr, available 24/7, paid on-call “On-call” crew performing transports $28,566 15% of call time at the higher duty pay rate of $18.12/hr Chief’s salary $47,112 125% of the duty crew’s wages Chief’s benefits $14,144 30% of wages Annualized Training Costs $11,319  Ongoing biennial re-certification costs $630 $70/person; half of the staff (9 of 18) are re-certified in any given year Initial certification exam $1,410 $705 for each of 2 new positions per year Biennial continuing education $9,279 $1,031 for each of 9 staff each year Total Annual Variable Costs (i.e. Annual Budget) $768,904 Administrative Costs (9% of Annual Budget) 69,201 Grand Total $838,105 * The number of responses includes transports and refers to the number of calls that the ambulance crew responds to. Discussion Total fixed, variable and administrative costs scale up from $838,105 in Tier 1 to $1,806,471 in Tier 3. Breakeven analyses suggest that low volume Tier 1 services with 25 responses/year experience operating costs of $33,524/response, while 400 and 800 responses/year experience $2,095/response and $1,048/response, respectively. Tier 3 services have a greater chance of realizing positive operating margins, with breakeven costs ranging from $1,187 to $821/response for volumes of 1,500 and 2,200 responses/year, respectively. Conclusions Contact: Yvonne Jonk <yvonne.jonk@med.und.edu> Gary Wingrove <wingrove@paramedicfoundation.org> The model provides important and timely information to rural communities, states, and regional policy makers in need of formulating strategic plans for the financing and provision of ambulance services