Joe Imel/Daily News An injured child is helped to one of more than a dozen waiting ambulances on June 25 after a fatal bus crash on Interstate 65 left more than 60 people injured.

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Twenty-eight of Kentucky’s counties have an ambulance tax to help support the operation of an ambulance service for its citizens. For some, it’s the only way to keep a service in operation.

Statewide, there are 235 licenses for some form of ambulance service, including air ambulance services and ambulance services operated at private industries, according to the Kentucky Board of Emergency Medical Services.

And in southcentral Kentucky, all counties, except Warren County, either do or will provide financial assistance through a taxing district or general fund obligations.

Most recently, Logan County joined the list by agreeing to provide a subsidy for the operation of privately held The Medical Center Emergency Medical Services, which is based in Bowling Green.

The county after July 1 will provide a $260,000 subsidy in monthly payments over the next year and then likely will renegotiate an agreement after seeing quarterly financial reports.

Butler County Judge-Executive David Fields said his county was forced to enact an ambulance taxing district when the general fund subsidy of Butler County EMS reached between $375,000 and $400,000 a year.

As for how the tax has been received, Fields said residents have only paid the tax related to automobiles so far. That has brought in about $21,000 since the beginning of the year.

“We are still having to subsidize from the general fund,” he said.

It will be November or December, when property tax bills are starting to be paid, that the service will get the bulk of its funding.

When those payments come due, Fields expects to hear some complaints.

“It’s a rough time right now for people paying for the rising costs of fuel and everything else,” he said. “But there really wasn’t any other choice for us. ... We have a good ambulance service with good employees who are doing a good job and nobody really wanted to get rid of them.”

In Barren County, the ambulance is a quasi-government operated service that also serves Metcalfe County, according to service director Mike Swift.

Metcalfe County helps support the service with a tax ranging from 3 cents to 6 cents, while Barren County provides a general fund contribution.

T.J. Samson Community Hospital in Glasgow and the city of Glasgow also help make up operating subsidies, Swift said.

The service is governed by a 10-member board - three people appointed by Barren County Fiscal Court, three people appointed by the city of Glasgow; two people from T.J. Samson Community Hospital and two people appointed by Metcalfe County Fiscal Court.

For each person the agency or government has on the board, it is responsible for making up 10 percent of the operating deficit.

In the fiscal year that ended in June, that subsidy was more than $277,000 each for Glasgow and Barren County and more than $185,000 for the hospital and Metcalfe County. Metcalfe County pays its subsidy with the tax it collects, Swift said.

Every year it becomes more difficult to make ends meet because reimbursement rates from Medicaid and Medicare are declining, Swift said.

“According to a General Accounting Office study, in rural areas, Medicare is underfunding (runs) by about 17 percent and Medicaid is three to four times that. It’s almost a giveaway,” he said.

Medicaid doesn’t meet any of the established reimbursement fees.

As an example, a non-emergency run for Medicaid run would be a $55 base fee and $2 a mile. The same run for Medicare would be reimbursed at 80 percent of a $180 accepted base rate plus almost $10 a mile.

The service’s fee for such a run might be $200.

If a person has both Medicaid and Medicare, traditionally Medicaid has made up the difference for the co-pay, but now it won’t pay anything if the fee is more than what it would have reimbursed for, Swift said.

With the $200 billed traditional insurance companies, the revenues might have evened out in the past. But now traditional insurance companies want to reimburse at Medicare’s rate, he said.

Peggy Cox, director of EMS in Simpson County, said the reimbursement is never enough.

“It makes it very difficult to provide pre-hospital care,” Cox said.

Franklin-Simpson County’s EMS is supported by a countywide tax, which, according to Simpson County Judge-Executive Jim Henderson, is expected to produce $437,000 in the current fiscal year.

Henderson said tax revenue has been adequate to help continue the service since the tax began in 1982.

Cox agrees that as it is now, the tax is adequate.

“But if there were to be any drastic changes in Medicaid and Medicare funding, two avenues would have to be looked at,” she said. “We would have to count more heavily on our tax base; or we would not be able to buy newer equipment and make do with what we have. Raising the rates doesn’t do any good.”

The biggest single payer to the ambulance service, aside from the tax, is Medicare. So far this year it has received $334,138. Medicaid is the lowest funding source, with most of those charges being written off, Cox said.

As an example of how the service is paid, Cox said for an advanced life support run with three miles to the hospital, the charge is $630.50. Medicare pays $285.92 and if the person has Medicaid, the remainder has to be written off. So the service gets paid about 46 percent of what it charges for a typical run.

“All aspects of health care are hurting,” she said. “But very little attention has been paid to the ambulance service side.”

The Medical Center’s EMS, in response to an open records request about run logs, said the service’s Medicaid reimbursement comprises about 7 percent of its funding. When it sought reimbursement from Logan County, Medical Center vice president Wade Stone said the company at that time had chosen not to seek a subsidy from Warren County.

“As a not-for-profit hospital, our focus is not on the bottom line - it’s about serving the community,” wrote Doris Thomas, vice president of Commonwealth Health Corp., in a written response to Daily News questions. “We understand that there are services needed that simply are not profitable, such as EMS or OB services. Reimbursements do not cover our expenses for those services.

“The large array of other services we provide through The Medical Center at Bowling Green currently helps offset the cost of providing EMS services in Warren County and has done so since 1974.”

As for why ask Logan County for the subsidy, Thomas said Logan County is in an outlying area.

“The circumstances are different in terms of costs and other factors,” she said.

To improve its EMS, The Medical Center in 2003 instituted a new dispatching system using a global positioning system. That system allowed the service to review the history of runs and examine patterns to determine what areas and times of day that have the greatest volume runs. Those changes have allowed for quicker response times.

A secondary benefit is that it is more cost efficient, according to Thomas.

Ambulance services may face further cuts with a proposed rule change from the Centers for Medicaid and Medicare Services that would allow Medicaid to not pay for any non-emergency ambulance transportation.

“With the state budget crisis being what it is, if the state is offered it probably would take that option,” Swift said. “That is going to be a detriment to all ambulance services, particularly to those in rural areas.”

But larger ambulance services are not immune to financial woes. Louisville Metro Ambulance Service earlier this year received a 10 percent cut in the funding the combined government provides for its more than $25 million budget, according to a Louisville Courier Journal report last week.

The cuts, the newspaper said, appeared to have resulted in slower response time to calls because fewer ambulance units were on duty.

Swift said, like many residents, the ambulance service also is facing higher fuel prices.

In the ’70s, the service switched to diesel engines. At the time diesel fuel was considerably cheaper than gasoline and allowed for an annual savings that would more than pay for a new ambulance, Swift said.

Now diesel costs significantly more than gasoline.

Last year, the service spent $69,000 for fuel.

“We have already exceeded that this year” with several months left, he said.

On Friday, the cost of diesel fuel in Warren County reached $4.05 a gallon.

The Medical Center, when it made its pitch to Logan County for a subsidy, said it would require a monthly fuel surcharge if the contract was longer than a year. The fuel surcharge would have ranged from $325 to $975 a month, depending on fuel costs.