Best Care Ambulance closing a sign of 'EMS crisis'

GILFORD — It's the end of an era in the Lakes Region medical community.

Best Care Ambulance Services, which operated in the Lakes Region for the better part of 31 years, closed its doors for good at 7 a.m. Monday. The loss of Best Care is a marker of what Stewart's Ambulance Service Executive Chair Justin Van Etten calls “an EMS crisis” in the state.

“If I live in the Lakes Region, I'm going be nervous about my ability to get transported if I need higher-level care,” Van Etten said. “There are hospitals [in New Hampshire] where you can only get transported to a higher level of care certain days of the week.”

Best Care President Scott Hodgkins pointed to boardroom politics and business disagreements with Concord Hospital-Laconia as the cause for his company's demise.

“Concord owed us some money and were trying to leverage us,” Hodgkins said. “They've now signed a contract with Stewart, who has a person on the board of directors.”

Hodgkins said Concord Hospital-Laconia owes Best Care roughly $150,000. Best Care's job was inter-agency transport, or moving patients with more severe needs to facilities like Dartmouth Hitchcock or to Boston.

“I can’t say it's six figures,” Pamela Puleo, chief advancement officer for Concord Hospital, said of the sum. “I can say I am aware we owe them money and our CFO has reached out to the owner to schedule a meeting and has been unable to schedule a meeting to discuss it.”

Puleo added that Concord Hospital did not have a contract with Best Care, but used their services, a move which may have lead to higher prices than Concord was willing to pay.

“I don't believe we ever had a contract with Best Care. Our predecessor [Lakes Region General Hospital] may have, but we did not,” Puleo said. Without a contract, “they could charge us whatever they wanted to charge us with some cases that could have been unreasonable and outside the norm.”

“When Lakes [Region General Hospital] was going under, we knew it, we understood they weren't going to be able to pay us,” Hodgkins said. “People had to move, we knew it, it was what it was, it was the right thing to do.

With the closing of Best Care, the Lakes Region and surrounding areas will now have fewer ambulances and EMS personnel until the gap is filled, a problem which is plaguing the entire state.

“This isn't Concord's fault, it's not Scott's fault,” Van Etten said. “It's happening everywhere. Franconia shut down their ambulances and said, 'We're not doing 911 calls anymore.' So if you dial 911 in Franconia, I'm not sure what happens.”

As Best Care makes its exit, it will leave Speare Memorial Hospital without an ambulance service to transfer patients.

“This definitely impacts our ability to transfer patients out to other facilities and we will now have to look at alternatives,” said Kate Tarbox, Speare's director of marketing and community relations.

"We have seen increased wait times before an ambulance service can respond to us. We will be actively reviewing our options to ensure that our patients get the transportation they need in a timely manner," wrote Speare CEO Michelle McEwen in a prepared statement Wednesday.

Hodgkins said Best Care could not survive as a business working exclusively with Speare after severing ties with Concord Hospital.

“Speare does 600 runs a year, that would be half of what we need to keep the lights on,” Hodgkins said.

The ambulance industry, according to Van Etten, is in a perilous spot due to a combination of staffing difficulties, decreasing insurance reimbursement and skyrocketing demand for patient transport.

“I'm really concerned as to what this means for the region. There's half of the companies doing it anymore,” Van Etten said. “What you're seeing is hospitals need more transport as a result of COVID. There's fewer EMTs and ambulances. We're working with a research company to see how bad the scale of this.”

That study has shown a troubling trend. Van Etten said, according to what they've learned so far, hospitals now require 50% more transpiration, and 30% more patient transports with longer distances.

“It used to be the worst case we'd take a patient to Boston, now we take them to Connecticut,” Van Etten said. “My personal record is to take a patient to a bed in Texas" from New Hampshire.

COVID not only increased the demand for transportation, it also reduced the number of health care personnel from burnout, and in the case of EMTs, the inability to host in-person classes to train them.

“More demand, fewer people doing the job, labor costs, vehicle costs and fuel have gone up,” Van Etten said. “The reason we're open is because we became one of the largest COVID testers and vaccinators and we took all of our profits from there and used it to keep the ambulance service alive.”

Hodgkins explained that he was able to keep his personnel by paying much higher salaries.

“Our EMTs started at $62,000 a year, our paramedics were doing between $85,000 and 90,000 a year,” Hodgkins said. “You didn't have people turning over.”

According to Salary.com, the average salary for a paramedic in New Hampshire is $47,000. An EMT's salary averaged out to $36,000.

Ambulance services like Best Care and Stewart's are paid by Medicare, Medicaid, direct patient billing and partially by private insurance. Private insurers have been steadily decreasing payouts to both ambulances and hospitals, and that's even if they'll cover an ambulance in the first place.

“Insurance companies, they have to have so many hospitals and doctor's offices in network,” Van Etten said. “The one thing they're not required to do is have ambulances in network. Most of the ambulances in New Hampshire are not in network.

“The largest insurer in the state of NH pays about 10% of what I charge.”

Over the last four years, Van Etten says, insurance companies have been reducing what they pay.

“It happens to hospitals, too,” Puleo said. “With reimbursement reduced, how do you provide the care you need to provide? It’s a very challenging environment. Every day is an interesting challenge for us as an organization to do things better and more efficiently and better to respond to the economics in the marketplace.”

Van Etten added that when an insurance company only pays a small fraction of an ambulance bill, the sum can fall on the patient directly, but at times, it's not feasible for the company to collect there either, leading to profit losses.

“You get in an accident, get transported and your bill is $2,000,” Van Etten said. “Your insurance gives me 150 bucks. Do I put you into collections to get paid, or do I suck it up because you've been in accident and are now out of work, and I write it off?”

So how does a company stay afloat? They overcharge.

“I have to get enough money to keep doors open, so you charge a ridiculous amount of money hoping someone pays the full bill,” Van Etten explained. “This is why ambulance companies are shutting down.”

This has led to a highly unpredictable payment environment for the service, one that makes operating and maintaining such a business difficult. “It used to be someone paid 2.5 to 3.5 times Medicare,” Van Etten reflected. “Now they pay less than Medicare to 10 times Medicare. You never know how much you're going to get.”

Although Best Care was not expecting to close its doors so abruptly, Hodgkins noted a small silver lining to his personal life.

“When you call Best Care Ambulance, you get me, if it's 2 a.m. that's me,” Hodgkins said. “We've been doing this a long time and we don't know anything else. It's kind of weird already. The phone stopped ringing. I shut off my phone. I haven't been able to shut off the phone in 30 years.”