half of all “sentinel” ED events—defined as “an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof”—were caused by delayed treatment. While this study was not centered on ambulance diversion, its findings are consistent with the argument that delays in treatment resulting from diversion can have deleterious effects on patients.

Third, the cost of maintaining an EMS system in a state of readiness is extremely high, and it is rarely compensated. The EMS reimbursement model used by the Centers for Medicare and Medicaid Services (CMS) and emulated by many payers reimburses on the basis of transport to a medical facility. This model ignores the increasingly sophisticated care provided by EMS personnel, as well as the growing proportion of elderly patients with multiple chronic conditions who frequently utilize EMS. Medicaid typically pays a fixed rate—as low as $25 in some states—for an EMS transport, regardless of the complexity of the case or the resources utilized. The fact that payers generally withhold reimbursement in cases where transport is not provided is a major impediment to the implementation of processes that allow EMS to “treat and release,” to transport patients directly to a dialysis unit or another appropriate site, or to terminate unsuccessful cardiac resuscitation in the field. In addition, many systems of all types provide both 9-1-1 call services and medical transportation. To make up for funding shortfalls, these systems often offset the cost of the former services with revenues from the latter.

EMS is widely viewed as an essential public service, but it has not been supported through effective federal and state leadership and sustainable funding strategies. Unlike other such services—electricity, highways, airports, and telephone service, for example—all of which were created and are actively maintained through major national infrastructure investments, access to timely and high-quality emergency and trauma care has largely been relegated to local and state initiatives. As a result, EMS care remains extremely uneven across the United States. Even when EMS is located within a publicly funded agency such as the fire service, it may receive a disproportionately small amount of fire service funding (including grants and line item disbursements), despite the fact that a large majority of calls to fire departments are medical in nature.

Fourth, EMS agencies face a number of personnel challenges. The training of EMTs and paramedics is uneven across the United States, and as a result, EMS professionals exhibit a wide range of skill levels. There are currently no national requirements for training, certification, or licensure, nor is there required national accreditation of schools that provide EMS training. In addition, recruitment and retention are significant challenges for EMS systems. The work of prehospital providers can be challenging and dangerous. EMS personnel face potential violence from patients; risks

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