Meeting the Demand as the Population Ages

There’s a demographic shift underway with the country’s aging population that will affect EMS call volume and workforce needs. By 2035, Florida adults 60 and older are projected to represent 31% of the population but will make up 62% of all EMS incidents. Older patients present with greater complexity, longer scene times, and higher acuity.

“Projecting EMS Workforce Demand in an Aging State: The Silver Tsunami,” a presentation at the September Innovation Conference for Emergency Medical Services at the Florida Center for EMS – CAMLS in Tampa, Florida, addressed future needs and what should be done to address them.

While Florida is a leading indicator with a rapidly aging, fast-growing state, it’s happening throughout the United States, noted Bruce Moeller, PhD, Florida Center for EMS executive director and University of South Florida Morsani College of Medicine Department of Emergency Medicine assistant professor. There are 11 U.S. states where those over 65 years old outnumber those age 18 and younger, he added, which also is the case in 50% of U.S. counties.

The year 2034 will be the year those aged 65 and older will outnumber those under age 18 nationally. Patients 65 and older use EMS at a rate two to three times greater than younger adults; adults 85 years old and older do so at higher rates.

“It’s not just about more calls, but also about the workforce already serving that population,” Moeller said. “The call volume is going to go up unless there is a concurrent increase in staffing and the resources needed to serve. The stress we've been talking about in our workforce is going to get worse.”

A Florida 2025 agency survey shows 1,884 reported vacancies and 56.7 of the responding agencies indicated shortages. That doesn’t account for attrition, Moeller said, adding the numbers will likely be “a little bit worse than that.”

Michael Lozano, Jr., MD, MSHI, Director of Research and Informatics, Florida Center for EMS and an associate professor at the University of South Florida Health-Morsani College of Medicine Department of Emergency Medicine, pointed out the forecast was constructed with Florida EMSTARS incident data from 2017 to 2025 with around 47 million incidents, which has risen to about 57 million. The research used a SARIMAX time-series forecasting framework based on three model variants of baseline, adjusted, and adjusted sensitivity.

The research also considered University of Florida Bureau of Economic and Business Research population projections, seven age cohorts modeled separately, and a COVID-19 disruption adjustment was applied for March 2020 to June 2021.

FTE calculations were used considering EMSTARS staffing configurations times projected incident volume plus unit hour utilization and annual productive hours. Moeller noted every agency staffs differently, so assumptions were made.

Addressing future demands, Lozano noted while there are currently 5 million EMS incidents a year, by 2035, it could rise to 7.7 million.

“In order to cover that number of calls, you'd need about a 49% increase in the number of full-time employees or full-time equivalent employees compared to the baseline at 2025. Something's got to bend unless you can find that many more people,” Lozano said.

While in 2025, 9,542 EMTs and paramedic FTEs were required, that number rises to 11,872 FTEs in 2030 and 14,195 FTEs in 2035. Lozano noted in 2026, there are around 2,100 vacancies. Moeller added attrition will increase. Research also shows every additional continuously staffed ALS ambulance will cost $1.25 million per year in recurring operating cost.

In the rural/urban variation, statewide averages mask concentration of demand in counties with the fewest workforce recruitment resources. Producing 4,653 additional FTEs requires a training pipeline with seating capacity, clinical sites, and licensure throughout that does not currently exist at scale.

Lozano added if two thirds of the calls in five to 10 years are going to be elderly patients, that suggests polypharmacy and multiple chronic conditions.

“That’s a different target patient set to train compared to the 1980s and 1990s when it was a little bit more clear-cut trauma and STEMI sort of stuff,” he said.

The Centers for Medicare & Medicaid Services (CMS) announced the ET3 program in 2019 to provide telehealth, treat-in-place, and alternative destinations for-low acuity 9-1-1 calls. Some 12.9% to 16.2% of Medicare-covered EMS transports involve conditions that are most likely nonemergent or treatable through primary care. The clinical rationale was to reduce unnecessary emergency department (ED) transports, improve quality, and reduce cost. At its launch, it had strong federal investment and stakeholder support.

However, only 38% of 111 participating ambulance organizations delivered even one ET3 intervention. ET3 encounters were less than 1% of participating organizations’ annual Medicare transports.

ET3 was supposed to run five years and ran under two before it was shut down not because of the clinical model but the implementation structure of workflow, training, technology, and public awareness was never adequately funded.

“We’ve got to be honest with ourselves,” Moeller said. “We blew it.”

Another option is treat-in-place, telehealth, and alternative destinations.

“We talk about unit hour utilization, and it actually it takes less time to implement one of these telehealth [programs] at the scene programs for a call than to actually take the patient to the hospital and sit on the wall and wait to get released,” Lozano said.

Studies show an estimated $560 million annual Medicare savings from reforming payment to allow alternative transportation destinations. An example of a successful program is the Emergency Telehealth + Navigation (ETHAN) program in Houston, Texas.

According to the program’s website, research shows 40% of patients don’t require the acute services provided by an ED and would be best served at a local clinic or urgent care.

EMS agencies transport roughly 21 million patients to overcrowded emergency departments each year, at an average cost of $3,500 per visit with more than $2,100 spent on transport alone.

Yet nearly 40% of those patients are nonemergency cases that could be safely treated outside the ED and only 39% end up admitted to the hospital.

The ETHAN program is designed to help local systems reduce strain, improve patient flow, and capture part of the $10 billion in potential ED savings nationwide. It works as follows:

• 9-1-1 call is received. EMS is dispatched.
• The EMT or paramedic conducts a standard field assessment to determine the patient’s condition and level of acuity.
• If the case is nonemergent, the EMS team initiates a secure video call with an ETHAN Health physician directly from the scene.
• The ETHAN physician evaluates the patient through telehealth and uses SYNAPSE, a clinical decision support tool, to determine the safest, most appropriate care pathway.
• Instead of defaulting to an ER transport, patients are guided to the right level of care — a clinic, urgent care, telehealth follow-up, or home care — ensuring faster, safer, and more efficient outcomes.

The program reaps about $928,000 in annual savings.

An Ontario, Canada, project showed community paramedicine home health visits had significant impact in reducing EMS calls among lift-assist callers and filled a primary care delivery gap.

Moeller noted with 7.76 million annual incidents in 2035 with no mitigation, 4,653 additional FTEs are needed as well as about 192 additional ambulance units at an annual value of $241 million. That’s flanked by conservative and aggressive models with different formulations.

“They reflect that we need to engage some strategies on how to mitigate some of the activity that is arguably coming our way, and how to deal with that,” he added. “Demand forecasting is a planning discipline. Every community is going to be different.”

It’s recommended to use age-stratified utilization data plus population projections to derive a number for actionable workforce planning inputs an agency’s leaders and budget process can use. Building a mitigation menu includes telehealth integration, treat-in-place protocols, alternative destination agreements, high-utilizer programs, and workforce pipeline assessment. EMS leaders are encouraged to choose one strategy and pilot it this year.

EMS leaders also are encouraged to engage their state EMS office and legislature on payment reform with the understanding that reimbursement for treat-in-place and alternative destination is the single highest-leverage policy lever available.

Lozano noted intergenerational communication skills will be key going forward. “One of the challenges is the ages of our learners now,” he said. “They need to understand that at one point, two-thirds of their patients are going to be elderly, and how to relate to these patients who are their grandparents' age, they may not have experienced that sort of communication. That would be helpful to include in our education.”

One conference attendee noted demands are being made on training centers without the necessary support, adding the emergency medicine sector hasn’t done an adequate job of taking the advocacy out to those who need to hear it.

Moeller concurred, saying “I don't know if we've got the bandwidth for the training, the recruitment, the retention.”

Regarding retention, Charles Sand, MD, FACEP, FACP, FAHA, said at the Becker’s Healthcare 16th Annual Meeting earlier this year in Chicago that he learned that using artificial intelligence may help ease the burden of time spent doing paperwork, adding its use should include governance and cybersecurity.

“They’re retaining employees at higher rates than they've ever seen in the last 10 years because all the mundane things are being sifted off to AI,” he said. “If you're not utilizing AI in EMS and your ERs, you're already way behind the times.”

Brent Allen, EMS director for the rural Union County, Florida, concurred that the EMS sector struggles to “market ourselves to ourselves. This is a great conference, but if this were a fire conference, this place would be packed. We are constantly referring to ourselves as clinicians, but in the grand scheme of things, we're still technicians. That’s one thing that we can start working on making a change.”

Allen pointed out advocacy is starting on the state level in Florida through the EMS Funding and Sustainability Coalition, comprised of the Florida Association of Rural EMS Providers, the Florida Ambulance Association, Florida Fire Chiefs Association, and the Florida Council of EMS Chiefs.

“We're working on Medicare, Medicaid, treatment in place, commercial insurance and reimbursements,” Allen said. “It costs me $1,100 to do a transport. My average reimbursement is about $550. If you were to take your truck to a mechanic and they said it’s going to cost $1,100 and you said, ‘I’m going to do $550,’ what would they say?”

Allen says the Florida Association of Counties is backing a policy centered on reimbursement.

“We need as many people supporting this as we can,” he said. “Reimbursement has been a problem for years,” he said, adding there are concerns about whether Amendment 3 will pass in the November elections in Florida. If passed, it would increase the homestead tax exemption as well as limit how counties and municipalities can spend property tax revenue.

“There's a crisis now, so we have to come up with alternative ways,” said Allen. “Funding and reimbursement is that way.”

Editor's note: Amendment 3 did pass. EMS World will provide updates on the impact as we learn more.