Indiana, PA - Indiana County

Citizens' Ambulance reaching critical crossroads

by on June 18, 2017 12:59 AM
Indiana, PA

The dominant ambulance company serving the Indiana County area may end 24-hour service from some of its stations at the end of the year, officials said, because of an ongoing financial crisis that’s wracking the emergency medical service industry.

The cutbacks in off-peak hours could jeopardize the creed that Citizens’ Ambulance Service, of Indiana, has followed for more than half a century — a pledge to answer every call for help without exception.

Officials warned that getting emergency medical care outside of a hospital could again be as iffy as it was in the 1960s when ambulance service was a side business mainly operated by funeral directors.

Leaders of Citizens’ said the organization has lost about $2.9 million in operating expenses since 2013 and registered a $135,000 deficit in the first four months of this year.

With a robust bank account that Citizens’ built over its history, the service has survived the financial crisis that has driven dozens of smaller and less prosperous ambulance providers out of business in the past few years.

Citizens’ responds to emergency and non-emergency medical calls 24 hours a day with fully equipped ambulances from seven stations in the region. That hasn’t changed, but to avoid draining its reserve fund and to protect itself from bankruptcy, Citizens’ has reduced its staff of emergency medical technicians and highly trained paramedics and cut the number of hours they work.

Staffing has been slashed in the neighborhood of 18 to 20 percent over the last two years, according to Chief Executive Officer B.J. Pino Jr., and Citizens has still answered every call for service — arriving in just 11 minutes on average.

Pino heads Ambulance Service Management Corp., the company that owns the facilities and employs the workers for Citizens’, an independent nonprofit organization.

He said more dramatic changes are inevitable if the losses continue.

Some of Citizens’ outlying stations in Blairsville, Hillsdale, Armagh, Plumville and Elderton could be shut down at night, and the number of medical crews on duty could at times be too few to respond to every call.

“For 2017, we budgeted to lose $614,000,” Pino said. “So far we are losing $34,000 to $35,000 a month and the reason it is only that amount, instead of $50,000 a month, is because we increased our billable trip volume. And we have no control over that, but we’ll take it while we can.

“But we’re at a point where decisions will have to be made. If things continue as they are now, we will not look the way we look now on Jan. 1, 2018.”

In turn, Pino said, the stress of helping critically ill or injured people would fall on other first responders, such as police and firefighters. In the big picture, it amounts to what Pino calls a public safety crisis.

“This will have a tumbling effect,” he said. “Not only for EMS, but where will the responsibility be shifted to? Volunteer fire departments? They are no better off when it comes to manpower.

“It’s a tear in the safety net. And this is a big one. There is nothing to replace it.”

It could happen.

On any given night, with reduced staffing, a handful of ambulance crews could be sent at the same time to treat a drug overdose, get a gravely ill nursing home patient to a hospital, or to back up police when they respond to a domestic fight.

That may leave a sudden heart attack patient in Brush Valley to wait for a medic unit to finish with a call in Smicksburg.

That may leave the injured occupants of a wrecked car in a rural area to depend on volunteer firefighters to treat fractures or head trauma. While some firefighters may have medical training, not all companies carry more than basic medical supplies and few have the right vehicles to rush an injured motorist to a hospital.

That also could leave a victim of a violent crime to rely on state troopers or local police to treat gunshot or stab wounds while paramedics respond from across the county.

In many cases, Citizens’ network of community-based immediate response personnel (IRPs) could provide a first line of care, but they also would have to wait for an ambulance to transport.

“That’s a personnel factor. We don’t have as many as we used to,” said Citizens’ Operations Manager Randy Thomas. “Hopefully we get one of them to respond, get to the scene and provide some stabilization.”

“There is going to be a tremendous amount of anxiety and fear,” Pino said.


Several major factors bear on why Citizens’ hasn’t seen a profit in several years. Some are fairly tangible, one not so much.

The community membership program that was the backbone of Citizens’ when it first organized in 1964 has dramatically diminished.

Despite an aggressive marketing campaign to get Indiana County residents to join, the number of memberships has fallen from 7,000 at the end of 2016 to about 6,500 at the end of April.

A membership entitles a patient to a 50 percent cut in out-of-pocket expense for a trip to a hospital from Citizens’ Ambulance Service. The company would only bill for half of the co-pay or half of the deductible for insured patients or half of ambulance cost for uninsured people.

“Our goal was to double that membership base and generate about $500,000 more. That didn’t occur,” Pino said. But there has been a silver lining.

“What has increased is the number of our supporters who have given us a few extra dollars out of the kindness of their hearts. They are helping to cover for the people who are giving us nothing.”

Ambulance companies across the state and nation also have taken a hit from belt-tightening by Medicaid and private insurance companies.

The Medicaid reimbursement rates haven’t changed in 13 years, Pino said, and the ambulance industry has united in its lobbying campaign for the government to raise the rates.

What hurts, too, according to Pino, is that private insurers follow the Medicaid rates to decide what they pay for ambulance service.

“We can no longer continue to do this, billing just $375 a trip or less when it costs us on average $500 just to turn the key,” Pino said.

“Medicaid pays us $120 for basic life support service and $200 for advanced life support. You can’t do business on those rates and that’s what creates the deficits.”

Explaining the service cost rates, Pino said Citizens’ and other round-the-clock ambulance providers have to add in more than just the hourly wages for the paramedics, the cost of medical supplies used for the patients and the fuel for the medic unit. Ambulance firms add the “cost of readiness,” a share of the cost of keeping EMTs and paramedics on duty 24 hours a day, just a few steps away from the ambulance, ready to answer when an emergency arises.

Pino said Citizens’ medics are on the road, treating and transporting patients about 20 percent of the time. They’re still paid for the other 80 percent of the time they spend in their stations, waiting for their pagers to go off with the next medical call from 911.

“There still is a huge amount of downtime but you still have that 24-hour window. You don’t know when the call is going to come,” Pino said. “And when 911 says ‘you’re going,’ we don’t have the luxury of asking ‘do you think they really need us?’ We’re out the door in two minutes, and during sleep time, we’re out the door in four minutes.”

Another factor is long-standing practice by Medicaid and insurance companies to pay nothing for ambulance response and treatment when no patient is transported.

Never mind that paramedics administer first aid or, on an increasingly common basis, use Narcan to revive a drug-overdose victim. Those success stories, officials say, avert costly care in a hospital emergency room but aren’t recognized as eligible expenses for insurance reimbursement.

Almost 1 out of 4 calls for the ambulance end with no one being transported, according to Operations Manager Thomas.

That includes 14 percent of calls where patients get necessary treatment, where people refuse treatment, or where the patient has died, and 8.6 percent of calls where paramedics can’t find anyone who needs care.

On every one of those calls, Thomas said, Citizens’ still bears the cost of readiness to respond.

The state House of Representatives last month approved legislation that would require private insurance companies to pay ambulance companies for no-transport calls when the medics render emergency care. Lawmakers unanimously approved House Bill 1013 and sent it to the Senate for consideration. That measure could remain in the legislative pipeline until December 2018 without action by the Senate or Gov. Tom Wolf.

The bill wouldn’t affect the Medicaid’s policy to pay nothing.

“That would cover a very small part of our business, but it would help,” Pino said. “Now we go out, we evaluate a patient, we don’t transport, we don’t get paid. Yet it costs us $500 to turn the key of an ambulance.”


The intangible major factor is the absence of a tax or other government support for the ambulance company, even though a moderate levy could erase Citizens’ Ambulance Service’s current operating deficits and keep all the ambulance stations open and fully staffed all the time.

Citizens’ officials said it’s the last thing they think of because it’s so unpopular.

Thomas said the service took a financial and public relations hit when a new municipal government tax was introduced in 2005. Boroughs and townships were enabled to collect $52 a year for the “emergency and municipal services” tax, and officials nicknamed it the EMS tax.

People misunderstood, and thought it was for emergency medical service.

“We still hear it on a regular basis. Do you know how many people say ‘I already give you $52 a year, why should I buy a membership?’” Thomas said.

Because of the confusion, government renamed the levy the “local services tax” in 2007. But it was too late.

“We took a 10 percent hit over two years for that. We used to have 8,000 to 9,000 members,” Thomas said.

Many local governments earmark a portion of the local real estate tax for local volunteer fire companies and public resistance to the fire tax generally is unheard of.

Why not a similar fee for ambulance service?

“I spend $30 a month to have my garbage removed,” Pino said. “Do you have any idea what we would have if we got $30 a month from every eligible household?”

Citizens’ board president Bill Staffen compared it to monthly charges billed by local government.

“Your borough or township says ‘we are going to recycle and here’s what you’re going to pay.’ And you have sewage service and you have to pay a fee,” Staffen said. “I don’t have a problem with that and I’ll pay for it.

“But I don’t know why this couldn’t go in the same direction. Those services aren’t life-sustaining, but this (ambulance service) is critical, in my opinion.”

“The water company recently asked for a $10 a month increase to improve their infrastructure,” Thomas said. “They can get that approved through the PUC to get what they need to improve what they’re doing. But we have no means like that.”

But again, Pino said, Citizens’ doesn’t pursue a tax, under the belief that a government fee could ruin the loyal, voluntary support of county residents who take out the annual membership.


And so Citizens’ Ambulance Service officials have continued the membership campaign indefinitely, in view of its potential for putting the service on better financial footing.

In Indiana Borough, the membership rate is 9.8 percent of about 4,900 eligible households, Pino said. Full participation could bring in an additional $300,000.

The rate is 19 percent of more than 7,300 eligible homes in White Township. Pino said Citizens’ could generate more than $400,000 in membership fees there.

Pino believes membership rates would be higher if Indiana-area residents understood the risks of possible ambulance station closings and service cutbacks.

“People surrounding the population hub where the headquarters are may be saying ‘what the heck, we are going to have ambulance service because this is the only place that breaks even in the operation,’” Pino said. “That’s true and it’s not true.

“There’s still the need for ambulance service in the periphery. People in Plumville will call 911 when they need help. That’s not going to go away.

“The folks have a comfort level in the immediate Indiana area but you have to understand that if you’ve only got three medic units to go around and they are on the road, when something happens in downtown Indiana there will be a very delayed or no response. We are still out there taking care of the larger population base.”

“The reasons why we were created will occur again,” Thomas said, recalling the stories of Citizens’ founders who were dissatisfied that sick and injured people could get no medical treatment before they reached the hospital emergency room.

“There won’t be a response,” Thomas said. “Somebody will probably die because we were not there and unable to respond.”

Citizens’ Ambulance Service fees this year are $75 per household, or $65 for senior households of age 62 and over. Area residents can learn more online at or may phone (724) 349-5511 for information.

PHOTO: An ambulance responded to a call on Route 56 near United High School. (Kevin G. Stiffler/Gazette)

Chauncey Ross is the Gazette’s fixture at Indiana Area and Homer-Center school board meetings, has been seen with pen and notepad in area police stations and courts, and is something of an Open Records Act and Sunshine Law advocate. He also manages the Gazette’s websites and answers your questions about them.
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