Welcome back to the “Life Under the Lights Bar and Grille”, your local dive bar filled with lousy food, tepid beer, bad ambiance, and great friends. Like any local Midwestern dive bar, it’s a come-as-you-are-and-sit-on-down-and-hang-with-your-buds kinda place. A conversation has broken out on the topic of “EMS Pay Sucks!! Let’s DO something about it!!” and me, your local blogger has decided to write a series of posts explaining the issues as I see them.

So, if you haven’t been here to read the last two, I suggest you go back and read them before you read this. If you don’t, well then that’s your choice. It’s a pretty informal place we have here.

Part 1: “EMS Pay Sucks!! Let’s DO something about it!!”

Part 2: “EMS Pay Sucks!! (Part 2) – Identifying the Problem

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In the last two parts here at the Life Under the Lights Bar and Grille, we’ve established that the time for talking about the issues is over, and that all EMS people need to band together in an effort to affect the pay rates in our profession. We’ve also established that this is a very complex issue and it can pretty much be said that if this was going to be easy, that it would have been done already. 

If you’ve read the comments that I’ve gotten on the other posts in this series, this is a hot issue with vastly different valid arguments that have been brought forth by people I respect. While I agree with a lot of what has been said, I would like to boil the issue down a bit further than it has been brought in the comments section and in the information that I have previously been exposed to. Basically it’s like this: By examining other occupations that are well compensated for their skills, we can examine the position we find ourselves in with our profession.

I think that it works like this, Well Compensated Occupations have these things in common:

1. There is a medium-to-high barrier to entry – Whether by education requirements, location, or the unpleasant nature of the work, there is a barrier to entering the occupation that requires work and/or an affinity for the location or work involved to get into the field. Not everyone can do it, the people that do it but cannot do it well easily fail out, and the people that can hang around to do the work are rewarded for it. Look at Dental Hygienists, teachers, and IT professionals.
2. There has to be a perceived value in compensating the people in the field at a higher rate to achieve higher performance – Look at the salaries of professional athletes and CEOs. They create value intensively based upon their knowledge and talents and the better they are at doing what they do, the more value they create for their employers. Think of it, if you could raise profits in your company $5million per year, wouldn’t that be worth an extra $1million per year in payroll?
3. The Industry they work in turns significant revenue overall – You could be the most talented Ice Sculptor in the world, but if you couldn’t find a market to sell your ice sculptures to before they melted, you wouldn’t make any money at it. Nor would you if you were the executive chef at a greasy spoon. Sure, you’d have the same job title, “Sculptor” or “Executive Chef”, as a sculptor that worked with Marble and Gold, or an executive chef that worked at a very fancy restaurant in downtown New York… but since the places you worked for weren’t making any money, you couldn’t possibly be paid very much; Even if you were as highly educated and more talented than your counterparts at the fancy joints.

I think that overall, point number three above sets the tone for us. Our industry doesn’t make much money, therefore, no matter how caring, compassionate, qualified, or talented we are, we won’t be making much for working in it. It’s pretty much that simple. Sure, some salaries are artificially inflated due to varying degrees support from governmentally levied taxes, subscriptions, or corporate support but if we were to stand solely on our current business model, the “fee for service” model where we only get paid if we transport and most of our customers do not pay then we’d all be much poorer than we are now. In fact, most ambulance services would be out of business.

I’ve heard the argument that one form of EMS delivery or another is “Ruining it for the rest of us” with people in one camp bemoaning “the privates” for being all about profit and not paying their employees due to the money grubbing nature of their owners, and people in another camp bemoaning “The Fire Guys” for holding the profession back and keeping educational standards low so that their fire guys don’t have to get the advanced education that would be required of other well-compensated healthcare professions. People in almost every camp bemoan the volunteers saying “If they do it for free, how can we expect people to pay for us!?”

Well, while all of those arguments sound plausible enough and may hold some truth to them, they’re crap when you really look at them. Should all restaurants be Governmentally based like the Fire Departments because then pay would be equal across the board? Right now people that work in Government cafeterias earn better money than those working in Flo and Gino’s Diner down on 5^th St. Flo and Gino’s Diner is *ruining* the restaurant business, right? How about IT professionals? People that work doing advanced networking at IBM earn WAY more than the people that do networking at your local newspaper office. Does that mean that smaller operations, and not large companies are *ruining* the IT business? Waitresses that work in Casinos and at Hooters make way more than do waitresses that work at your local fancy chain restaurant… Is TGI Friday’s to blame?

Every business, governmental organization, or organization on Earth in one way or another, is a system that takes in money and other resources, does something to it, and then spits out something with perceived value to it. The military takes in vast amounts of money, manpower, and other resources and doesn’t make a dime doing it. Its value is in protecting the interests of the society that funds it and therefore it’s usually a governmental pursuit. Diamond mining takes a lot of resources and money to perform as well, but since diamonds are sold for huge profits, it’s a pursuit of the private sector. I don’t get much into politics on my blog, but I can say that personal experience has taught me that capitalism works and that government rarely does anything better, more efficiently, or faster than does the private sector. Government bodies, by definition, rarely are any good at staying within budget, let alone making a profit, and when they do try to make a profit, they fail spectacularly… e.g. Fannie Mae and Freddie Mac. By definition, the Fire Service doesn’t make a profit, and they have branched out into providing EMS in a lot of cases, solely to get a piece of the transport revenue to support their other operations. Private services, by definition, are doing the same… Neither one is inherently evil.

And neither are volunteers. I work in rural areas and I’ve always lived in them. Heck, my hometown had more cows than people and yet I still needed someone to bring the ambulance whenever the farm hand got trampled on by Bessy. Rural areas have voluntary agencies where community members step up to the plate to provide services out of the humanity they have to their neighbors and also because of the fact that if they didn’t do it, nobody would. That’s not evil, it’s just a reality of rural life. (There are benefits to the volunteer services that I will expound upon in a later article not in this series as well.) (Disclosure, I’m a volunteer paramedic and dang proud of it).

A paramedic blogger who I really respect, TOTWTYTR (Who writes the blog “Too Old to Work, Too Young to Retire”) offered the following comment on my post “Paramedics Providing Physicals? Decreasing Healthcare Costs and Improving Patient Care – EMS 2.0”

“Chris, you seem to be intent on finding more for paramedics to do. I’m not sure why, when there is a “shortage” of paramedics we need a heavier work load or “expanded scope”. We’re also likely intruding into someone else’s work space in the process.

Nor can I say that giving more for the same amount of money of benefit to the profession. In fact, I’d opine that it will have the opposite effect.”

His argument looks good too, when you don’t share the same definition of a business as I do and you don’t view EMS as a business, which it is. Remember my third point above, the one about industries that don’t make any revenue being unable to compensate their employees at a reasonable rate. My idea in the above post, to have a paramedic provide your next annual physical, is another service that we can use to sell for a profit. The belief that we can survive solely on transport revenue has not panned out when most of our transport revenue is based upon dwindling government reimbursement through Medicare and Medicaid (and the looming universalization of healthcare) and the tax revenues we rely on from local governments is starting to be eaten away. We have to find new sources to generate revenue from. We’ve got to compete in the marketplace to either do old things better and/or cheaper or do new things before anyone else does them. Our profession is not insulated from capitalism just because we layer ourselves in compassion.

So to end this long rant, I think that we can go a long way towards solving our pay problem by turning our attention to the three points above.

First, educational standards must be universally standardized, universally raised, and must be owned by our professional governing body. While we should probably never make a Master’s degree the entry point to ambulance work, it shouldn’t be a GED either. Probably some PE classes should be in there as well, or at least the ability to pass them. Go Get Educated!

Second, we have to educate the public about what it is that we do and why being good at it is important. If the public thinks that a volunteer service with a BLS response is adequate, then they’ve never laid there with a broken femur only to be bounced down a gravel road next to an EMT-Basic that can’t give them a squirt of Morphine. They’ve also never had their MI go into cardiogenic shock because the BLS volunteers couldn’t give them correct medications to mitigate the damage. They have to be shown convincing evidence of these facts before they will, and someone has to be our cheerleaders. Honestly, I’ve never seen an “EMS Cheerleader” or someone who was promoting the profession to the public, that hasn’t been skewered by their peers. Maybe NBC’s “Trauma” wasn’t the most accurate show in the world… but neither was “Top Gun” and we loved that movie and wanted to be a fighter pilot after seeing it (last week, again). Be an EMS Cheerleader in your community!

Third, your EMS service needs to go do something to make itself money. Figure out what you can do to boost revenue, and do it. Try new things. There are a lot of business ventures that have a good synergy with EMS.. Perhaps you could sell those little “I’ve fallen and I can’t get up” buttons and home-safety devices to the elderly in your community. Perhaps you could do home healthcare. Perhaps you could offer OSHA safety consulting to business and industry in your jurisdiction. All of these things are very much part of what we can, and probably will be doing in the future. Seek out New Ideas and Profitable Ventures!

I haven’t figured out the title to the next post in this series, but I’ll be writing it tomorrow. I’ve loved the debates that have been popping up in the comment’s section and I’m sorry that I haven’t jumped in there much as of yet. I’m just trying to keep my ideas to the main posts, and then I’ll come back and debate when I get out what I want to say. You all have been creating some great energy and while we’re not going to agree on this, I’ll say it again “Perfection is the Enemy of the Good Enough”. Complete agreement is not necessary for us to act upon a consensus.