Bake Sales Won’t Sustain Wyoming EMS, but a Few Reforms Might 

​​​Emergency medical services (EMS) are basic lifesaving infrastructure for any community. This infrastructure is based on readiness: whether responding to a heart attack, a car crash, or a fall at home, EMS providers are expected to be ready at all hours, in all weather, across some of the most remote terrain in the country. 

But that readiness comes at a cost — and in ​sparsely populated ​rural states like Wyoming, low- service volume simply can’t pay the bills.​     ​ 

A recent report from the Wyoming Department of Health examined the financial reality facing Wyoming’s ground (as opposed to air) EMS providers and outlines practical recommendations to improve the system’s long-term sustainability. At its core, the economic challenge is straightforward: given the small population in many large frontier areas, the revenue generated by EMS in a fee-for-service environment does not cover the cost of being ready to respond. But there are steps states can take to ensure its residents have access to emergency services. And in Wyoming, the state legislature and the Department of Health are making those steps a reality by blending state funds and federal Rural Health Transformation (RHTP) dollars. 

The $30 Million Wyoming Problem 

Statewide, Wyoming’s ground EMS system costs an estimated $67 million per year to operate. Yet even under optimistic assumptions, EMS agencies can only generate about $37 million in service revenue. That leaves a gap of roughly $30 million annually. 

This gap must be filled through various subsidies, such as county taxes, hospital support, grants, fundraising, and volunteer labor. Some of these supports are more reliable than others​. With declining volunteerism, for example,​ keeping the system afloat has become increasingly difficult. 

EMS Costs Are Largely Fixed 

The mission of EMS is rapid response. That means ambulances, equipment, and trained personnel must be available 24 hours a day, 7 days a week, 365 days a year — even if no calls come in. 

For even the smallest EMS agency in Wyoming, this requires: 

• At least one ambulance ready to deploy at all times 
• Staff on call or on duty, regardless of call volume 
• Ongoing training to maintain clinical skills 
• Equipment, facilities, insurance, and administrative capacity 

These readiness-driven costs are mostly fixed. Labor alone accounts for about 63% of total expenses for a typical rural ambulance service. Other major costs, including training, equipment, maintenance, and facilities, don’t disappear when calls are infrequent. Only a small portion of expenses, such as fuel and medical supplies, varies with call volume. 

Revenue Depends on Calls — and Wyoming Has Fewer of Them 

Unlike readiness costs, EMS revenue generated by its delivery of services is made in a fee-for-service health care payer environment. This means it depends almost entirely on volume. EMS providers are paid when: 

1. Someone has a medical emergency​     ​ 
2. The patient is transported to a hospital​     ​ 
3. The claim is correctly submitted​     ​ 
4. An insurer pays the bill 

While many health care providers face this challenge, EMS has additional complications. Only about two-thirds of EMS calls result in a transport, which is usually required for billing. The remaining calls — often “lift assists” for people who have fallen — are generally not reimbursable. 

Even when a transport occurs, billing is complicated. EMS providers must navigate complex insurance rules, Medicare and Medicaid reimbursing well below private insurance rates, and most of the time payment is not collected from people without insurance, who cannot afford to cover the cost. 

In large rural areas with few people, however, even if a service were to bill and collect perfectly, there simply aren’t enough calls to cover fixed costs. Some EMS agencies respond to fewer than 100 calls per year, while larger agencies may see 9,000 to 10,000.​​ 

Many of these smaller agencies rely on volunteer labor (who respond when paged). This increases response times by the five to ten minutes it takes for volunteers to leave their day job and get to the ambulance, which can lead to worse outcomes for residents in these areas. 

What the Data Show 

The report’s findings highlight the scope of the challenge: 

• Wyoming’s 44 EMS providers respond to about 77,500 calls per year​;​ 
• Roughly 34% of calls are not reimbursable​;​ 
• Medicare accounts for 40–50 percent of EMS call volume, reflecting the strong link between age and EMS use​;​ 
• An estimated 71 (off peak timing) to 113 (at peak timing) ambulances must be on call statewide at any given time​ to meet readiness demands;​ 
• About 58% of residents live within a 9-minute expected response area, while 6 percent live more than 30 minutes from an ambulance 

Practical Steps Toward Sustainability 

There is no single solution that will erase the $30 million gap for Wyoming, or similar gaps in other rural and frontier states. But the report outlines two practical recommendations that the state is acting on to solve the problem.​     ​ 

First, the state ​will​​ ​explore supporting a statewide EMS billing contractor that will help smaller agencies with the overhead of billing and collecting. Using existing data systems, this contractor would submit insurance claims on behalf of participating EMS agencies. This approach is intended to improve billing and collection rates, reduce administrative burden for small agencies, lower overall costs, and improve data quality. Wyoming is using its RHTP funds to procure this billing service for state EMS providers and is considering incentivizing provider participation in the future.  

Second, the report recommends targeted matching funds to encourage EMS agencies to voluntarily move to more sustainable EMS models, such as fire/EMS integration, which have a tax base for fixed costs, since putting out fires is not paid for on a fee-for-service basis, and Critical Access Hospital (CAH)-based systems that can receive cost-based Medicare reimbursement. The Wyoming Department of Health is dedicating a significant portion of its RHTP funding to this end.  

In this initiative, EMS providers will be financially incentivized to consolidate into regional entities (i.e., centered around a fire department or CAH), which have to demonstrate how they are reducing administrative overhead and modernizing technology and operations with interoperability, tele-crisis stabilization, and the use of staff to provide care to community members between emergency visits. 

​​To further these efforts, t​he Wyoming ​S​tate ​L​egislature has been instrumental in approving Wyoming’s RHTP application, and also in appropriating additional state funds to increase Medicaid reimbursement for EMS, with tiered higher rates for lower volume rural and frontier providers​.​ ​     ​ 

A System Worth Supporting 

EMS will never be inexpensive — and it shouldn’t be. The ability to respond quickly and expertly to medical emergencies is essential infrastructure, just like roads or utilities. 

The question is how EMS can be sustained and how to do it in a way that’s stable, efficient, and fair over the long term. With thoughtful consideration of the economic fundamentals of matching fixed costs with fixed revenue, Wyoming and other rural states can strengthen their EMS system and ensure that help can always be on the way​,​ ​n​o matter where you live.