EMS in the United States is provided in one of five ways: fire service, private, third service, public-utility and hospital-based.

The fire service model is where EMS is run by the fire department. The personnel who staff the ambulances are usually cross trained as firefighters, and assume those duties at fire scenes. Since most fire departments in the country who follow this model are seeing 80% or more of their calls as EMS runs, having firefighters sitting around, waiting for a fire seems inefficient. So while there are no fires, they are put to work running EMS calls.

The advantage to this system is that it is more efficient to minimize the amount of down time that crews have and put them to work. The disadvantages to the system are that 1) most of the personnel would rather run into burning buildings than clean up grandma’s feces filled diapers. 2) If one of these people rises to the level of chief, you get an entire EMS agency that focuses more on the 20% or less of the organization’s responsibilities, and virtually ignores the primary mission of EMS, and 3) To adequately serve potential patients, EMS resources must be matched to meet demand. Fire departments have historically deployed ambulances using a fixed neighborhood station model, and many continue to use 24-hour shifts. This results in lower efficiency, with too many resources during non-peak times and non-peak neighborhoods, and not enough resources during non-peak times and in non-peak neighborhoods.

The next government run system is the ‘third service’ model, in which EMS is run as a branch of local government as a stand-alone service. Like its public-safety counterparts, it is completely owned, financed, and operated within the local government structure. The advantages here are that everyone in the EMS organization is charged with and working on the delivery of emergency ambulance service, and management is directly responsible to local officials.

The disadvantages here: As with all government run models, it is common for third-service and fire-based organizations to be evaluated by a level-of-effort approach instead of performance outcomes. This means no repercussions exist if the service underperforms. Poor performance is often addressed by simply adding resources. Another disadvantage is that control of expenditures is dependent on the local government’s budgetary and managerial processes. This makes it difficult to keep spending appropriate, as the people doing the budgeting are either invested in the process (the EMS chief) and spend too much, or they know nothing about EMS delivery (the city commission/mayor’s office), and spend too little.

There is private EMS, which is where a private company provides EMS service to the community, and is funded entirely by user fees, billed to those who use the service. Since the model also provides the more lucrative non-emergency transportation between hospitals, private homes, and nursing homes. In combination with lower wages, less opportunity for advancement, and higher expectations for productivity, the provider can usually make EMS profitable. The advantage here is that this service costs the taxpayer very little, but the disadvantages here are that significant oversight is required to prevent the company from cutting too many corners, and that employee turnover and burnout rates are generally high.

There is the “public utility model,” where the EMS agency acts like a public utility like the electric company. They are a for profit service that is contracted by the local government to provide service to the community, and they are paid a fee by the local government, and also bill the people who are transported to the hospital. The majority of the funding (if not all of it) is through these user fees.The advantage here is that the contractor is held to a standard, and if they do not live up to that standard, they can be replaced.The disadvantage is that this is a variation on the “for profit” system, and the disadvantages here are the same.

Similarly, hospital based systems see the same difficulties as the PUM and the for-profit models. In my area, there were two hospital based ambulance services, but they only did the more profitable interfacility non-emergency transports. A few years ago, one was replaced by a contract with Rural Metro. The other is still there, but is still relegated to interfacility transports.

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TOTWTYTR · December 20, 2010 at 12:20 am

Actually there are something like 50 models of EMS delivery in the US when you count all of the combinations and include volunteers.

For example in NJ, ALS must be provided by hospital based systems, but there are commercial, fire based, and volunteer BLS squads.

I used to work for a hospital based ALS service, but BLS for the city was provided a third service.

This is one of the bigger challenges to trying to develop a "national" model for EMS delivery.

Of course the fire service would solve that by making everything fire based.

Divemedic · December 24, 2010 at 1:39 pm

That is true, but all of the other systems are simply combinations and variations of the basic types above.

Q99 · March 1, 2011 at 8:12 am

There was a comparison of the models within the past year or so, in one of those glossy-paged magazines.

It showed, all things being equal, for every dollar of income, what percent went to what. The PUM presented the most overhead, with the private being the least.

I've been searching for that article for a few days now, but haven't located it. Anyone else know which article I'm referring to? If so, kindly point me there!

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