ALTAMONT – The Altamont Rescue Squad is on life support. 

At a Knox Town Board meeting on Sept. 26, the not-for-profit ambulance organization’s director of operations, Warren Quinn, told the board members that the squad would not be submitting a budget request this year since he’s unsure whether it will be able to continue serving the town in its current form. 

At the moment, the squad, the oldest in the state, which used to be a volunteer squad, is now made up primarily of paid members, Quinn told The Enterprise this week. Altamont Rescue serves Guilderland and Knox alongside Guilderland’s own ambulance service, known as GEMS, which was created in 2018. 

At that time, Quinn told The Enterprise he was not worried about the town taking over Altamont Rescue’s operations. “We’re providing our contractual agreement to them, and there’d be no reason for them to look at taking us over,” Quinn said in 2018. The town has always been supportive, Quinn said; he added that the town had stated that “it’s not their objective to take over our operations.”

For decades, Guilderland was covered by two volunteer squads — Western Turnpike and Altamont. As volunteers became harder to find and training for first responders became more advanced, paid workers were added to the squads.

In June 2018, the Guilderland Town Board voted unanimously — with no previous public discussion — to establish its own ambulance service and hire enough emergency medical technicians to staff the ambulance 24 hours a day.

The future of the Altamont Rescue Squad came into question after a policy change implemented by GEMS earlier this year, which Quinn said at the Knox Town Board meeting this week decreased Altamont’s transports by 70 percent. In addition to subsidies from the municipalities it serves, the squad makes money by billing the insurance companies of people they transport to the hospital in their ambulances. 

“They’re pushing us out,” one of the rescue members said at the Knox meeting. “I hate to say it, but we’re the oldest rescue squad in the state, and we’re going to be gone.”

The Guilderland policy has to do with how the two different organizations, which have different capabilities, cooperate on service calls. 

GEMS offers advanced life support, or ALS, which means it can perform certain medical procedures such as installing IVs, administering medications, intubating patients, and more. These services are overseen by a paramedic, Guilderland’s EMS director Jay Tyler told The Enterprise this week, adding that the town has had an ALS program since 1986, and has served the town of Knox since 2003. 

Before Guilderland established its ambulance service, ALS was offered via fly-car, he said.

The Altamont Rescue Squad, meanwhile, offers only BLS, basic life support, which is handled by an emergency medical technician, or EMT, and involves things like cardiopulmonary resuscitation, or CPR, and bleeding control, among others. 

The town of Knox pays for Guilderland’s ALS services but contracts with the Altamont Rescue Squad and Helderberg Ambulance, which is a volunteer organization, for BLS service. 

The new policy, implemented in March, essentially states that, if a patient requires ALS, he or she will be transported on an ALS-equipped ambulance (meaning Guilderland’s ambulances, in this case) while a BLS patient will be transported on a BLS-equipped ambulance.

Two ambulances are required to respond to every call in Zone 3, which is the Altamont area, Tyler explained, and a paramedic determines what services are needed. 

“Sometimes what will happen …,” Tyler said, “is an ALS call will go out, we’ll take our paramedic off of our ALS ambulance, put them into a BLS ambulance, and then a BLS call will go out, and we’ll have to send an ALS ambulance to a BLS call.”

So, in effect, the new policy means that Guilderland will no longer put its own paramedics on an Altamont ambulance, instead ensuring that patients are transported on the vehicle that best suits their needs, he said. 

The roughly dozen Helderberg and Altamont rescue workers who showed up for the Knox meeting, however, felt that Guilderland has been overreaching in an attempt to get more money for calls, declaring what ought to be BLS calls as ALS ones. 

“Typically, 50 percent of our calls resulted in non-transports,” Helderberg Director Neal Hogan told the town board. “The patient … refuses transport for whatever reason. He has a bit of a car accident, might have had some alcohol or something [and doesn’t want to be tested]. For the other 50 percent, of that, 20 percentage points are legitimate ALS calls. For Warren to be experiencing 70 percent ALS is way beyond the norm.”

Tyler, however, says that the makeup of calls has been consistent before and after the policy was implemented, at a ratio of 60 advanced to 40 basic, and that it would be malpractice for paramedics to intentionally initiate ALS service for the purposes of earning money for their organization. 

“That would be a huge, huge issue,” Tyler said. “The New York State Department of Health could get involved. I mean, that’s a wild accusation that is really unwarranted, and it’s not true.” 

Rather, the policy was made based on recommendations by Guilderland’s medical director, Dr. Donald Doynow, Tyler said. 

“This policy is rooted in our commitment to providing the highest level of care for each patient’s specific needs,” he said. 

Bringing up the question of timing, which Tyler said had been asked before, he said he had no good explanation. 

“We probably should have done it a long time ago,” he said. “But, you know, Altamont’s always been a good neighbor, and we just held on longer than we should have. Hospital wait times have definitely exacerbated the issue.”

Patient billing

Part of what made the policy change seem sinister to many in the Knox Town Hall that night was the belief that, unlike Helderberg and Altamont Rescue, GEMS “hard-bills” its patients, meaning that whatever expenses can’t be covered by a person’s insurance are billed directly, and that debts are sought aggressively, something Tyler also denies.

Soft-billing, on the other hand, refers to the practice of taking only what the insurance offers and not asking any more of the patient. 

For Quinn, who lives in Knox, this would mean that — if Guilderland takes on BLS services in Knox, which it has offered to do for the same amount that the town pays the Altamont Rescue Squad — Guilderland would be making extra money on the service, getting the money through both taxes and private bills. 

“Why do they need that money?” he asked The Enterprise rhetorically after the meeting.

Tyler said, however, that Guilderland does not hard-bill, and would be using the money for the additional services that it would be providing compared to the current arrangement with the town. Ultimately, GEMS would be getting money in the same exact way that Altamont has been, he stressed.

“All we’re saying is that [Knox] paid Altamont this amount to do the transport. There’s wear and tear on vehicles, there’s a contract, you’re going to be taking our ambulance out of service, just give us what you were giving Altamont,” Tyler said. “There’s two separate services, the life support and then the ambulance.” 

As for private bills, Tyler said that Guilderland doesn’t use aggressive practices that people associate with hard-billing, and that Guilderland’s billing process is the same as Altamont’s and Helderberg’s. 

“We have a collection agency that makes phone calls. That’s about all they do,” he said. “Nobody has ever gone to collections, nobody’s credit has ever been hurt.” 

The reason Guilderland uses a collection agency, Tyler explained, is that many patients keep the checks that their insurance agency sends them for the ambulance expenses. For those who genuinely can’t afford it, the town has a hardship program in place.

“In an agency like ours that does 7,000 calls a year, you see it more than you can imagine … and there’s not much we can do about it,” he said of patients keeping money from their insurance companies, adding that a  solution would be direct-pay legislation that’s pending. 

The bill, which authorizes insurance companies to pay “nonparticipating or nonpreferred providers of ambulance services” directly, has passed both chambers of the state legislature and is awaiting the governor’s signature.

“If you look at some of these folks that take ambulance trips once a month, and they start to take more and more ambulance trips closer to Christmas, it’s a little bit curious, and they don’t remit the bill to us,” Tyler said. “That’s where the collection agency actually came in. It’s for those folks. It was never designed to harm or dissuade elderly folks or folks who can’t afford  EMS.” 

Tyler also said it’s “crucial to emphasize that no one should hesitate to dial 9-1-1 due to financial worries.”

Of social-media posts that criticized Guilderland for its billing practices and service, Tyler said that much of it was misinformation — in one instance put forward by a disgruntled employee, as revealed by a town investigation. 

GEMS has an operating budget of around $3.5 million, Tyler said, with EMS revenues covering $2.8 million, or 80 percent. 

Knox’s decision

Quinn told The Enterprise that the Altamont Rescue Squad won’t stop answering calls, subsisting off its reserve funds in lieu of municipal subsidies while it figures out its next steps. He said it’s possible that the squad will resort to being entirely volunteer-based again. 

But with the squad’s future up in the air, and the Knox town budget coming due soon, Knox has to figure out how it will make sure it has ambulance service covered, without relying too heavily on mutual aid, which is an agreement where an outside agency will respond to a call in an area where no local support is available. 

Hogan said that Helderberg Ambulance, which is struggling to attract and retain volunteers, who make up the entirety of the organization, would not be able to easily expand its services to the whole town. 

“For reasons I don’t understand, we only have four volunteers from Knox,” he told the town board. “We used to [have more]. Knox is about one-third of our calls consistently, year after year.”

Hogan said that Helderberg currently has 26 members capable of riding in an ambulance. The organization serves Berne in addition to Knox, and is stretched thin as it is, as The Enterprise reported last year. A costly attempt to attract recruits through the State University of New York failed, bringing in four recruits who all ultimately dropped out of the program. 

As mentioned, Guilderland has offered to expand its services for the same price, though Quinn took issue with Knox paying GEMS the same amount it would pay Altamont. 

“I have no problem with Guilderland taking over the town of Knox,” Quinn said. “They will be providing 24/7 response from Altamont, hopefully, so the response times will be hopefully better than they currently are. I’m just upset with the $30,000 they want because they’re going to be billing everybody. They’re going to be making tons of money so there’s no need for them to have [Knox’s] money.”

Regarding response time and resources, Tyler said that Guilderland is fully equipped for service to Knox, and that negotiations are ongoing to have an ambulance stationed in Altamont. The estimated response time to Knox, depending on location, would be six to 14 minutes, he said.

Guilderland is currently building a third ambulance station in the western part of town near the town’s golf course at the intersection of routes 146 and 20, which is less than 7 miles from Altamont.

Other towns where volunteer squads have gone under, as many have in recent years, have contracted with the Albany County Sheriff’s Office, though service through the county has always been much more expensive, and is getting more so as it raises personnel wages to be competitive, since the sheriff’s office is experiencing similar difficulties with recruitment as volunteer squads.

Tyler said that officials from Guilderland will appear before the Knox Town Board at Knox’s Oct. 10 meeting to discuss its proposal to the town.