JACKSON, Miss. (WLBT) - With each hospital closure, ensuring high quality health care for Mississippi’s most rural residents becomes that much harder, forcing small counties with dwindling tax bases into paying for ambulance service that may not provide the fastest response -- because neither the state nor one-fourth of the state’s counties -- regulate those response times, according to a 3 On Your Side joint investigation with Mississippi Today.
Since 2010, five hospitals shut their doors across the Magnolia State. A February report from Navigant, an independent consulting firm, said nearly half of the state’s rural hospitals are in danger of closing due to “high financial risk.”
With fewer hospitals, the emergency response process -- which connects patients with life-threatening conditions to the very treatment opportunities they need -- becomes even more crucial in bridging that healthcare gap.
Our analysis found nearly 1 in 5 Mississippi counties doesn’t have an emergency room, so when 911 calls go out in these parts of the state, those minutes spent waiting for an ambulance matter even more.
“All of a sudden, she just passed out. It scared me to death," said Walter Chisholm, who lives in eastern Amite County.
Chisholm immediately called 911 that day, keeping his wife of 63 years calm while they waited for help to arrive.
He suspected her condition was serious because she had already been diagnosed with a carotid artery blockage weeks earlier.
When the AMR ambulance arrived, Chisholm said 49 minutes had passed from the time he dialed 911.
“You got somebody laying there that you love like I love my wife, I thought she was gone," Chisholm said. “It was just -- it was terrible.”
The Chisholms live near the Amite-Pike county line, 15 minutes away from Southwest Regional Medical Center in McComb.
But because they live in Amite County, only AMR is allowed to answer emergency calls there because of the county’s contract with the ambulance provider.
AMR dispatched the ambulance from Centreville, which is more than 40 minutes away from Chisholm’s house.
Chisholm: "If it had been life-threatening, I mean, she might not have made it by the time we got to the hospital."
That ambulance also sits on the Wilkinson-Amite county line, and serves both counties, meaning that one ambulance covers more than 1,400 square miles.
“You better hope you’re not the third heart attack in the county that night or you’re gonna be waiting a very long time," said Ryan Kelly, executive director of the Mississippi Rural Health Association.
Natchez serves as a staging area of sorts for AMR, the largest provider in Mississippi.
As soon as the company’s Centreville ambulance gets called into service, another one comes down from Natchez, which takes an hour to arrive.
“EMS transportation is among the very top things we have to be focusing on as a state, because very few of our communities have adequate access to EMS transportation, adequate meaning there’s residual backup to where if ambulances are out on a run, there’s some access to where you can get to the hospital in a timely manner," Kelly said.
That, in turn, leads to longer response times.
3 On Your Side found some areas of the state are more vulnerable than others.
Fourteen Mississippi counties don't have emergency rooms.
Eight don't even have hospitals.
And our joint investigation found several of the state’s more rural counties have more than a dozen bridges out, according to data provided by the Mississippi Department of Transportation.
Per capita, Wilkinson County has the most bridges out of service in the state.
“An ambulance was called to a location out in the Perrytown area, and there was a bridge closed there. AMR knew the bridge was closed there, so they were trying to reroute through the national forest to get to the call and got lost in the national forest," Wilkinson County Administrator Bruce Lewis said.
Lewis said that patient did not fare well after it took EMTs almost two hours to reach her.
“Your healthcare is really more applicable to your zip code than anything else. Where you live affects your health outcomes. And it is a sad truth," Kelly said.
To keep costs down, many counties have to opt for cheaper, not better, coverage.
These factors add up to a perfect storm of challenges for ambulance providers in areas that need them most.
3 On Your Side teamed up with Mississippi Today to examine response times in those areas and take a closer look at the companies involved.
To accomplish that, we requested response time data from those fourteen counties without ERs, plus Amite, Pike and Hinds counties.
The average response time for counties without ERs came in at 14 minutes.
In Wilkinson County, it’s 22 minutes.
The longest single response time in that county -- from January 2018 -- clocked in at 78 minutes.
Response times are considered performance-based standards, and the state’s department of health doesn't regulate that.
Instead, it leaves that responsibility to county governments.
However, dozens of those don’t regulate them, either.
3 On Your Side requested the ambulance contracts from all 82 counties and found that, of the 50 counties that sent back information, more than half -- 29 -- had no response time requirements.
Wilkinson is one of them.
“We’ve never had a problem with [response times]. If we did, we would address that with them. They’ve always timely responded," Lewis said.
How is response time calculated?
Let's use a call from Franklin County and Rural Rapid Response as an example.
The response time clock doesn't begin when 911 first takes the call, but only when it is transferred -- or that information is provided to the ambulance service.
From there, it ends once the ambulance arrives on scene.
On this particular call, EMTs made it to a Franklin County home in just 10 minutes.
After picking up the patient -- a young woman who had passed out -- paramedics started an IV and made her comfortable before continuing on to the hospital in McComb.
Twenty-six minutes later, they arrived and transported the patient inside.
In that case, paramedics were able to transfer that patient in 23 minutes.
But sometimes, EMT and Rural Rapid Response owner Tyler Blalock says, that transfer takes hours with Jackson-area hospitals.
When it does, that patient has to wait on the gurney until they can be carried inside.
That period between hospital arrival and transfer is called wall time.
Blalock believes that those Jackson-area hospitals now rely on that extra wall time instead of scheduling more nurses to transfer patients.
“They’re now continuing to take advantage of us, and whether it was intentional or unintentional, now EMS has been been burdened with the fact that if an ER is busy, that we now have to take care of their patient that’s on their grounds because they don’t have enough staff or rooms to be able to take care of that patient," Blalock said.
Another possible reason for that increase in wall time: most county contracts with ambulance service providers require the provider to respond to all 911 calls that request an ambulance.
If a patient calls with a nonemergency issue like a headache, for example, that ambulance cannot refuse service.
To Blalock’s point, though: federal law -- and an informal attorney general’s opinion -- state that once a patient arrives at a hospital, even by ambulance, that patient becomes the hospital’s responsibility.
“For us to continue to provide care and leave another county, my primary county, uncovered for four to six hours to me, it’s unacceptable," Blalock said.
It’s also a reason he believes response times can’t really be trusted, because wall time is entirely outside the ambulance provider’s control.
Blalock also believes that response data can be manipulated.
“Who is the agency that checks your response times and how can you validate that response time is accurate?" Blalock said. “Most of the time, larger companies, or most all of my competitors, have their own dispatch center who tracks their own response times. And so it’s voluntary to say that ‘I did this response time in that amount of time.’”
Better response time also usually comes with a higher price tag.
However, our joint investigation found that typically, the larger population for a county, the cheaper the service for taxpayers.
Take the Jackson metro area, home to more than half a million people.
Those three counties combined pay less than Wilkinson’s entire $80,000 contract.
Madison and Rankin contract with Pafford, paying almost $16,000 and $23,000 a year respectively.
Hinds has an agreement with AMR, which costs them almost 37-grand.
“That ambulance company is by default saying ‘well, county, we won’t charge you as much because we’re making more money from the businesses in your area.'"
You see, the business model of an ambulance company works because it's either supplemented by nonemergency calls or a subsidy from the county.
It often makes very little off the 911 calls it's required to answer.
“What people don’t realize is one 24 hour a day ambulance costs about $800,000, $850,000 a year, and that’s not paying your guys well. That’s very limited benefits that they have," Blalock said.
That’s why Blalock said his coverage for Franklin and Lawrence counties costs taxpayers in both counties more than half a million dollars annually altogether, among the most expensive contracts in the state.
Even then, he maintains his business is barely profitable.
Still, they keep going.
“I can drive you right here in this small little town and point out the houses of people who are alive today from the care that I’ve provided, let alone the care that all of the other crews in this town have provided. These are our neighbors, these are our friends. It’s more than just a way to make money. You have to care about people to do the job," Blalock said.
More than forty counties sent contract information to us for this story.
Several county officials claim they don’t even have a contract with the hospital that provides ambulance service, which in turn makes it harder for that county to hold the ambulance provider accountable.
Perhaps the most surprising aspect of this contract roundup: 24 counties didn’t send any documents (public records) in response to our records requests within seven business days, which is a violation of state law.
3 On Your Side sent emailed those requests to officials in the following counties: Carroll, Clarke, Copiah, George, Holmes, Humphreys, Jasper, Kemper, Lamar, Lauderdale, Leflore, Lincoln, Lowndes, Marion, Noxubee, Pearl River, Simpson, Smith, Stone, Tippah, Tunica, Union, Warren and Yazoo.
All of those emails went to verified email addresses and were delivered; some were even read by the officials in question.
State law requires a public body to produce a public record within seven business days or provide a written explanation for why it took longer than seven days.