1. 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 ( Responses/Yr)
Tier 3 ( 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 ( Responses/Yr)
Tier 3 ( 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 $
450
$ 1,862
1200
$ 1,114
1900 $
500
$ 1,676
1250
$ 1,069
1950 $
550
$ 1,524
1300
$ 1,028
2000 $
600
$ 1,397
1350 $
2050 $
650
$ 1,289
1400 $
2100 $
700
$ 1,197
1450 $
2150 $
750
$ 1,117 $ $
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
Gary Wingrove
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