Sparse populations covering large geographic areas make the per-person cost of providing emergency care expensive.  EMS has fixed costs in operations and capital costs, i.e., ambulance vehicle license, insurance, and maintenance; facility or building rent and maintenance; liability insurance; training for volunteers, staff, and physician adviser; utilities; and supplies, including expensive medications with short shelf lives.  Most of these fixed costs are constant regardless whether an EMS provider responds to 10 or 100 calls monthly.  The current reimbursement system, such as Medicare, is based on per trip (or per mile) and does not consider the cost of constant readiness.

Recruiting and retaining staff and volunteers who are available, trained and committed is one of the major challenges currently being reported by Colorado rural EMS providers.  Rural and frontier EMS agencies are often dependent on volunteers, and volunteerism is declining as people focus on their paid jobs and as rural areas experience a decreasing and aging population.  Retaining EMS providers in rural areas is challenging because of demanding expectations to conduct administrative work and fundraising, health risks, and the costs and time to meet training requirements.  Dedicated EMS providers often find themselves saddled with administrative duties that they have little or no training to perform the tasks, which can lead to resignations.

Rural communities do not have the volume and associated profit potential to attract private sector EMS services.  Call and run volumes are low, which is not attractive for private sector ambulance services.  Low volume results in higher costs per run.  Rural areas are dependent on the public sector to provide EMS, or on associations established with volunteers.

Local governments in rural areas have a lower capacity to fund programs through taxes.  Tax bases in rural areas founded on property and sales taxes are often low, resulting in limited ability to raise funds to support EMS.  Private property market values may be low in comparison to urban areas, and limited retail services result in lower sales tax collections.  Particularly in the west, much of the land is federally owned, eliminating local tax support as an option.

Maintaining skills in a low-volume area is difficult for rural communities.  Obtaining regular training, which often incurs travel expenses for trainees, is challenging in rural areas.  For volunteers, training can also mean time away from work and additional personal expenses.  While using technology, such as the internet to provide ‘distance training’ opportunities, can remove the distance barrier, not all rural areas have adequate digital information infrastructures to make distance learning truly feasible.

Rural areas have a higher proportion of seniors.  This factor may also result in an increase in the number of calls from those suffering age-related injuries and illnesses.  Additionally, there is a higher reliance on Medicare for reimbursement.

A lack of public transportation results in a reliance on EMS for non-emergency transport.  Across the country, some EMS providers in rural and frontier areas have stopped offering non-emergency transportation, such as trips to distant doctor’s office from home and back, in order to keep EMS resources available for local emergencies.

There is a higher proportion of uninsured people in rural communities than in urban.  Uninsured individuals are more likely to delay seeking healthcare, especially preventive healthcare, which can lead to greater use of emergency services when illnesses become serious.

Historically, both Medicare and Medicaid have inadequately reimbursed rural EMS providers, particularly those in low volume call areas.  In an effort to address the special circumstances of rural EMS providers across the country, CMS implemented significant changes in reimbursement for all ambulance services in 2002.  CMS implemented a new fee schedule for ambulance services that stipulates a base payment per trip that varies by the type of service provided and added a mileage payment, which varies by length of the trip.  It is hoped that this new methodology will better serve rural areas, especially since there is a higher proportion of seniors in rural communities and therefore more reliance on Medicare as an EMS funding source.

Medicaid provides base reimbursement rates for 0ne-eay emergency medical service trips that, similar to Medicare, are inadequate for low volume service areas.  EMS agencies participating in Medicaid must accept the Medicaid reimbursement level as payment in full.  They cannot bill the consumer for a remaining balance in an attempt to meet their actual costs.

Contributing to the rural-urban disparity in the provision of EMS services is the increased closure of rural hospitals and medical practices.  As a result, there is increasing pressure on EMS providers to provide services outside their scope of practice.  In addition, there is a greater call for emergency and non-emergency medical transportation to even more distant facilities and services.

Rural EMS systems usually have longer travel time over greater distances to medical facilities, which is made more difficult and dangerous in adverse weather.  The further a patient is from an emergency medical facility, the more a patient will benefit from an advanced level of local EMS; however, rural and remote areas are less likely to provide advanced levels of EMS.  The advanced levels of care are difficult to establish and maintain in areas that experience insufficient volume.  Paramedics will often relocate to areas that can compensate them for their skills and experience, making retention a problem for rural EMS providers.