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A stretcher stands by as firefighters and paramedics work during a training scenario involving extraction from a vehicle in Sterling on Wednesday, July 17, 2019. After a private ambulance company shut down, the Sterling Fire Department began providing emergency medical services to a 2,000-square-mile area of northeast Colorado (Austin Humphreys, Special to The Colorado Sun)

When flames shot from the third-story balcony of a downtown Frisco condo this spring, a firefighter riding in an ambulance got there first, zipping a block over from patrol on Main Street, scoping a plan of attack and attaching the first hose the moment a full fire engine arrived. 

In tiny Holyoke, population 2,215, when ambulances aren’t on an emergency run, the paramedics now take their rigs to make house calls and sort medications for elderly patients or make sure there are handrails for frequent slip-and-fall residents.  

And in Sterling, in the northeast corner of Colorado, the ambulance service gave up its employee-taxing runs of patients to Front Range hospitals, hoping to retain local paramedics by boosting morale. 

Rural and mountain emergency medical services are trying just about anything to keep their money-losing ambulances running across Colorado’s rugged or remote terrain. High costs, low reimbursement rates and scarce job applicants are forcing ambulance services to consolidate with fire responders, take on new tasks between emergency runs, and outsource fast-growing transport runs to bigger metro hospitals. 

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Meanwhile, the demands on rural EMS keep rising. Rural counties in America tend to have sicker patients and populations aging faster than metro areas, according to national researchers, while new pressures like the opioid epidemic and competing job offers, bring other challenges. Hospital and EMS managers in Colorado’s smaller towns grew accustomed years ago to constant crisis mode in their ambulance ranks.

“Like everything in health care, it’s just so crazy expensive, and people have to think outside the box,” said Michelle Mills, chief executive officer of the Colorado Rural Health Center. 

Sterling Fire Department firefighter and paramedic Carson Bedford takes a seat at the front of a fire engine at the station in Sterling on Wednesday, July 17, 2019. (Austin Humphreys, Special to The Colorado Sun)

Colorado’s rural EMS services wrestle the same problems as other sprawling states where most of the population is concentrated in one or two urban corridors. Rural counties tend to have a higher percentage of the population using low-reimbursement insurance such as Medicare, Health First Colorado (Medicaid) or veterans care, making every ambulance run a money loser for the local hospital or emergency services district. Staffing has been a challenge for decades, made even harder by the runup to full employment in the last decade of U.S. economic expansion. 

And the Affordable Care Act, while signing up tens of thousands more rural Coloradans to subsidized or public insurance plans, guaranteed higher demands on rural ambulances — studies show people who become insured use ambulances and emergency rooms at far higher rates.

“When I talk to older folks, the biggest change I’ve seen is that before there were a lot of things people wouldn’t have thought about calling the ambulance for. But for some folks that’s the only medical care they have, and that’s their way into the system,” said Sterling Fire Chief Lavon Ritter, who also oversees the Logan County ambulance service as the separate entities were merged for cost savings in 2012. 

In Sterling, EMS calls have gone to 3,000 a year from 1,200 in the two decades Ritter has worked in the county. This summer, Sterling Fire and Logan County asked Banner Health, which runs hospitals and clinics across Northern Colorado, to take over ambulance transports to Front Range hospitals. 

“Transports were having a huge impact on my guys and morale,” Ritter said. They had no control over transports that needed to happen in the middle of the night, and had to be on call to cover unexpected transports when off duty. “So to maintain morale and keep 911 resources as our highest priority, we worked this out with the county.”

Ritter is also systematically looking for people in the community who will take emergency responder or other medical training at the local community college, so “we can latch onto them as volunteers and part-timers and grow our own.” 

In Summit County, it took 30 years to make a sudden change, with Summit County Ambulance rigs finally getting a new coat of paint as “Summit Fire & EMS” this summer.

After decades of debate and the ambulance service struggling with both revenue and staffing issues, the two entities merged in a formal intergovernmental agreement to create a department with 114 fire and EMS employees. The move comes four years after Summit voters approved $1.5 million in dedicated ambulance taxes for the ambulance service; the 2022 sunset of that tax sped up negotiations on the merger.

The combined service will cross-train more of its personnel in both firefighting and medical response, fire chief Jeff Berino said, in hope of leading to more rapid response successes, like the downtown Frisco condo fire. 

Sterling Fire Department firefighter Jason Vorderberg holds open the hood of a burning vehicle as firefighters Carson Bedford and Connor Routzon approach with a hose during a training scenario. (Austin Humphreys, Special to The Colorado Sun)

Transports are Summit’s biggest challenge as well, Berino said. On winter ski days, Frisco’s hospital trauma unit is often full. “At any one time, we may have four ambulances out of the county bringing people to Denver locations,” Berino said. (Summit has eight total rigs, but not all are available all the time due to staffing issues or repairs.) 

 “On a snowy day, that round trip for us can take four to five hours, waiting for the tunnel to open. The county is a victim of its own success,” he said. “Skiers get hurt.”

Traffic accidents are another big challenge. “We have the highest (altitude) stretch of interstate in the U.S.,” Berino said, and on Loveland Pass, “the highest hazmat tunnel in North America.”

Summit boasts about 62% collection rate on ambulance charges, considered high for rural counties, enough to be sustainable. Here’s what that revenue is up against: New ambulances cost $190,000 with only basic equipment; new engines are $600,000; new ladder trucks are $1.2 million to $1.5 million.

“Ski visitors expect metropolitan services when they are up here, and we strive to do that,” Berino said. “But we are taxed on weekends in winter and summer. It’s all hands on deck.” 

In Holyoke, south of Sterling on the Eastern Plains, Melissa Memorial Hospital is trying to preserve its ambulance service by running with an idea pioneered in Eagle County and spreading nationwide: Using paramedics’ down time to offer home visitation services that can greatly improve quality of life and, just as importantly, get reimbursed and keep the rigs rolling. 

Until recently, Philips County had an all-volunteer EMS service shared between Melissa Memorial and Haxtun Hospital District. Again, transports out of the county were a major problem. Surrounding ambulance services had to make the transfers, from 45 minutes away, and taxpayers wondered why another county’s rigs were taking local patients away to far-flung hospitals, said Trampas Hutches, Melissa Memorial’s administrator.

Brady Ring came over from Sterling as full-time paramedic director, and the county settled on creating a professional paramedic service. But they couldn’t afford to have paid professionals sit idle between calls. Eagle County, meanwhile, had been a national pioneer in sending its paramedics and ambulances out for scheduled home visits. 

Medicare and some commercial payers offer some reimbursement for such calls, which often involve helping a hospital-discharged patient readjust to home life or sorting of overlapping medications.

“We’re trying to redesign health care as we know it,” Hutches said. Readmissions of patients are down, and “the revenue increase is significant,” he added. “So overall, we went from being a kind of pain point to a successful turnaround program.

Michael Booth is the Sun’s environment writer, and co-author of the Sun’s weekly climate and health newsletter The Temperature. He is co-author with Jennifer Brown of the Colorado Book Award-winning food safety investigation “Eating Dangerously.” Booth was part of teams that won two Pulitzer Prizes for breaking news. He also writes frequently about inexplicable obsessions that include tamarisk, black-footed ferrets and tire fires. Booth also serves as the underpaid driver for four children, and plans to eventually hike every inch of Colorado.