By Michael A. Loiz, Chief Executive Officer, The Public Safety Consulting Group

In brief: Many municipal EMS agencies meet every 9-1-1 performance target and still can’t close the funding gap. Reimbursement from commercial insurance, Medicare and Medicaid keeps tightening while demand grows. Adding interfacility transport (IFT) can create sustainable, mission-aligned revenue while easing transition-of-care delays, improving clinical handoffs and building career paths. It works only when 9-1-1 coverage is protected first, clinical governance comes before convenience, and the agency grows no faster than it can responsibly handle.

Key Takeaways

• Meeting 9-1-1 KPIs doesn’t guarantee a sustainable EMS budget, especially for largely self-funded municipal agencies.
• Ambulance wall time, ED crowding and delayed discharges are connected symptoms of one system under pressure, not separate problems.
• Not every patient needs the same response, destination or care pathway. IFT gives scheduled and non-emergency transports a planned pathway of their own.
• Done well, one decision addresses several problems: revenue, patient flow, clinical ownership, equity of access and workforce retention.
• Success depends on protecting 9-1-1 coverage, strong clinical governance, ongoing evaluation and realistic growth targets.

On October 28, Shell Piercy, Chief Paramedic Officer for Australia’s Northern Territory, posted a reflection from the Bali 2026 Emergency Care Conference called Beyond the Ambulance: Rethinking Emergency Care Through a Systems Lens. Her presentation, Mind the Gap: Translating the Transition of Care, came down to three short lines on a slide:

One patient. Multiple clocks. Unclear clinical ownership.

One sentence from her article has stuck with me: “patient flow is a whole-of-system challenge.” Another follows close behind, drawn from Bill Kinch’s session at the same conference: “Not every patient requires the same response, the same destination, or the same care pathway.”

I read those lines from the other side of the world, and they described almost exactly the conversation I’ve been having with EMS leaders here at home. They’re also the clearest way I’ve found to explain why a municipal 9-1-1-only EMS agency might decide to add interfacility transport (IFT) as a service line. In one of my other roles, I’ve been part of exactly that decision.

I want to be honest about how agencies get here, because in my experience this isn’t a growth strategy dreamed up in a good year. It’s a decision leaders feel they have to make.

Hitting Every Target Isn’t Enough

Many municipal agencies have always been 9-1-1-only services. They built their identity around doing that one job well, and by the measures our profession uses, they do. They meet their response, clinical and operational KPIs.

Performance alone doesn’t fund a system, though.

EMS agencies all over the country are operating in a healthcare funding environment that keeps getting tighter. When coverage shrinks and access to everyday care gets harder, people don’t stop getting sick. They wait longer, their conditions get worse, and more of them turn to the one part of the healthcare system that always answers: 9-1-1. EMS becomes the safety net for the safety net.

The hard part is that the same funding pressures that reduce people’s access to care also hit the reimbursement that keeps EMS running. Demand rises while the dollars behind each response shrink. Those two trends can’t keep pulling in opposite directions without something giving way.

Expected to Make Our Own Way

There’s a part of EMS funding most residents never see.

Many municipal EMS agencies are largely self-funded. Most of what it costs to run the service comes from what they bill for the care they provide, not from the tax levy. That’s something those teams can be proud of, but it also exposes a gap in how communities think about public safety.

When a police or fire budget falls short, the answer is generally to fund the gap, because everyone accepts that those services have to be there. EMS is usually held to a different standard. We’re expected to make our own way, and our options for doing that are few: commercial insurance, Medicare and Medicaid.

Each of those has limits. Commercial insurers manage their costs by limiting what they pay, and EMS claims are no exception. Medicare and Medicaid reimbursement has long paid less than the cost of providing the service, and it moves with every budget debate in Washington and in state capitals. That’s been true no matter which party holds the majority. When those programs are cut, the conversation rarely gets around to a simple question: where is EMS supposed to get its revenue?

A common answer is “just recruit more volunteers.” I have enormous respect for volunteers. They built EMS in this country, and many still serve their communities with extraordinary dedication. But in an economy where many families need two incomes just to get by, fewer people have the time to give. Volunteerism is something to treasure. It isn’t a funding plan.

So EMS agencies do what they have to. They hire more people to meet their communities’ growing demand, even as the funding sources they depend on keep getting squeezed. More demand, more staff, less reimbursement per call. Left alone, that cycle wears systems down until something breaks, and when EMS breaks, it’s patients who feel it first.

Some suggest that moving EMS under a different structure will solve the problem. Every model has strengths, and I know outstanding EMS systems that operate as part of fire departments, hospitals and other organizations. But changing who EMS reports to doesn’t change what EMS costs or what it gets paid. The funding gap is still there; it just moves into someone else’s budget, where it’s harder for the public to see. I’d rather keep that gap visible, be transparent with the community about it, and work on real solutions.

I don’t say any of this to make a political point or to criticize any agency or model. Every EMS leader I know, in every kind of system and community, is dealing with the same math. It’s simply the environment we all work in, and pretending otherwise doesn’t protect anyone.

So leaders face a choice, and in reality it isn’t much of a choice. They can keep doing exactly what they’ve always done and hope the numbers work out, or they can think differently about what a municipal EMS agency can be.

Symptoms of One System

Piercy makes a point I think American EMS needs to hear. What Australia calls ambulance ramping, and what we usually call wall time or offload delay, is more accurately a transition-of-care delay. As she puts it, these challenges are “too often” framed as ambulance problems or emergency department problems. In reality, rising ambulance demand, ED crowding, access block and delayed handovers are “interconnected indicators of a health system operating under significant pressure.”

That framing changes how a 9-1-1 agency looks at its own work.

For decades the model has been simple. Someone calls 9-1-1, we respond, we treat, we transport, we hand off at the emergency department, we clear. Our performance measures and our identity both live inside that window.

That window is real and it matters. But the patient doesn’t live inside it.

Every call starts a clock we can see: response time, on-scene time, transport time, time to hand off. What we often don’t see, and honestly haven’t considered ours, are the other clocks running on the same patient:

• The clock in the emergency department while a patient waits for an inpatient bed or a transfer to a higher level of care.
• The clock on a discharged patient who is medically ready to go home or to a skilled nursing facility but is still in a hospital bed because a stretcher transport isn’t available.
• The clock on a resident who needs to get to dialysis, an imaging appointment or a specialist and has no realistic way there except an ambulance.
• The clock on the family trying to coordinate all of it.

When those clocks run long, the cost doesn’t stay where it started. A bed that can’t be emptied is a bed the ED can’t fill. An ED that can’t move patients up is an ED where crews stand at the wall. The wall time we measure on our side is often just the visible end of a delay that started somewhere upstream, in a discharge that couldn’t happen or a transfer that couldn’t move.

From the patient’s point of view, as Piercy writes, dispatch centers, ambulance services, emergency departments, hospitals, primary care, urgent care and community providers “are not separate entities.” They’re “components of a single healthcare journey.” Most of us measure our piece of that journey very well. We haven’t been asking much about the rest of it.

In my experience, that’s the moment it clicks: the new service line that can help keep an agency sustainable is the same one that can help close some of those gaps.

The Right Response for the Right Patient

Bill Kinch’s session, The Waiting Room on Wheels: Managing Non-Emergency Patients, gets at the other half of this. For years the default answer for almost any patient who needed to move was an emergency ambulance, whether or not the need was an emergency. That’s a mismatch, and it’s hard on everyone: the patient, the hospital and the 9-1-1 system.

Not every patient needs the same response, destination or care pathway. A scheduled discharge home, a transfer to a higher level of care, a dialysis appointment and a cardiac arrest are four very different needs. A well-designed system matches each one to the right resource at the right time.

For a 9-1-1 agency, IFT can be part of building that match. It gives scheduled and non-emergency transport needs a planned, appropriate pathway of their own, so they aren’t waiting on an emergency system built for something else, and so the emergency system stays available for emergencies.

One Decision, Several Problems

What usually moves this decision forward is realizing that IFT isn’t just a revenue answer. Done well, it addresses several problems at once.

Sustainable Revenue That Fits the Mission

IFT brings in new, scheduled, billable work that uses the clinical infrastructure a community has already invested in. In one of my other roles, it’s part of a broader long-range plan that includes ordinance updates, service expansion, diversified revenue and expanded career opportunities, so the agency isn’t relying on emergency billing alone to sustain the service.

Patient Flow Is Emergency Care

Every hour a medically ready patient waits in a hospital bed for a ride affects the ED, and that affects 9-1-1 crews. Helping move patients through the system on time isn’t a side business. It’s upstream protection of emergency response.

Continuity of Clinical Ownership

“Unclear clinical ownership” is the line from Piercy’s slide that stayed with me most. When a patient is handed from facility to transport to destination, every handoff is a chance for information, medications or expectations to get lost. A well-built IFT intake makes the sending clinician’s report, the right level of care and clear escalation criteria part of the booking itself, not something figured out later in the hallway.

Equity of Access

Some of the people most affected by tightening healthcare funding are the same people who struggle most to get a timely, dignified ride to the care they need: older residents, people with disabilities, and families without the resources to manage it alone. Piercy reminds us that patient-centered care starts with dignity and with health systems that are safe, respectful and accessible to every member of the community. A local, publicly accountable transport option is one way to deliver on that.

The Workforce

Scheduled transport work creates real career pathways: more full-time positions, predictable shifts, new clinical exposure and room to grow supervisors and educators. A system that wants to keep its workforce has to give that workforce somewhere to go.

This Is Not an Easy Decision

I don’t want to make this sound simple, because it isn’t.

Interfacility transport is a different business from 9-1-1. It has its own operational demands, documentation requirements, payer rules and relationships with facilities. Agencies that do it well have spent years learning how, and I have a lot of respect for them.

Expectations matter just as much. A community that has always known its municipal agency as the emergency ambulance service rightly expects that when it calls 9-1-1, that agency will be there. Any change to how resources are used has to earn and keep that trust. Staff have expectations too. Many chose their agency because it’s a 9-1-1 service, and asking them to take on scheduled transport work raises fair questions about workload, identity and what kind of organization they’re becoming.

Those concerns can easily stop this effort before it starts. Moving forward takes some courage. In my experience, leaders have to listen to those concerns, take them seriously and design the program around them instead of past them. The agencies that succeed are the ones that decide the risks of standing still are greater than the risks of change, and that they can do this in a way that stays true to who they are.

Innovation With Assurance

Piercy makes another point every EMS leader should take seriously: “innovation alone is not enough.” New models of care have to be supported by “strong clinical governance, robust evidence, clear accountability and ongoing evaluation,” and the real challenge is “finding the right balance between innovation and assurance.”

That balance should shape how any agency builds an IFT program.

• Clinical governance comes before convenience. Acceptance, level-of-care decisions and clinical escalation should be owned by agency leadership and run under medical oversight and state EMS requirements.
• Clear accountability. Every request needs an owner, a clinical screen and a defined path for escalation. A request that doesn’t fit the agency’s level of care should be reviewed, not automatically accepted.
• Easy for the requester, rigorous for the agency. Hospitals and residents should find booking simple and responsive, while HIPAA, CMS and payer documentation requirements are met behind the scenes.
• Ongoing evaluation. IFT should be measured the way 9-1-1 is: timeliness, clinical quality, patient and facility feedback, and above all any effect on 9-1-1 coverage. If the data shows something isn’t working, change it.

The goal isn’t just efficiency. It’s better outcomes for patients, with safety, quality and equity of access protected along the way.

Doing It the Way That Fits the Community

Piercy also notes that effective health systems “cannot be designed through a one-size-fits-all approach.” They have to reflect the realities of the communities they serve.

There are many good models for IFT across this country, and many agencies run it far larger and more complex than a typical municipal service ever would. No single approach is better than the others. The right one is the one that fits the community, the agency’s size and its mission.

In my experience, that comes down to a few commitments:

• Grow only as far as you can responsibly handle. A municipal agency doesn’t need to capture every transport in the region. Take on what you can staff, manage and do well, and expand only when you’ve earned it.
• Don’t chase unrealistic revenue targets. The goal is a stable, sustainable service, not maximizing volume. If a target would push crews or 9-1-1 coverage past what’s reasonable, it’s the wrong target.
• Stay who you are. A municipal 9-1-1 agency is a 9-1-1 agency first. IFT extends that mission; it doesn’t replace it.
• Protect 9-1-1 coverage first. Plan IFT capacity around dependable, dedicated staffing time, not whatever downtime you hope to have. If the emergency system needs the resource, the emergency system gets it.
• Shared fleet, shared standards. Where possible, a crew stepping into an IFT unit should be stepping into the same truck, the same layout and the same standards as on a 9-1-1 call. That consistency is a safety strategy, not just a purchasing decision.

IFT Is a Bridge, Not the Destination

Piercy describes secondary triage, alternative care pathways, community paramedicine, urgent care integration and transition-of-care reform as “critical components of a sustainable healthcare system.” For many agencies, IFT is the first step in that direction, not the last.

In one of my other roles, IFT planning is running in parallel with a community health assessment, done with emergency management, public health, senior services and home-care partners, ahead of choosing a Mobile Integrated Healthcare pilot. Early analysis of repeat 9-1-1 use there suggests that a relatively small group of residents accounts for a meaningful share of encounters. Many of them move back and forth between home, hospital and facility, which makes them exactly the patients IFT serves. I suspect many agencies would find the same pattern in their own data.

That’s the whole-of-system idea in practice. 9-1-1, interfacility transport and community paramedicine aren’t three separate businesses. They’re three points of contact with the same people, and when one accountable agency connects them, the gaps get smaller.

None of this works in isolation. It depends on partnership with hospitals, medical directors, dispatch centers, local government and the community providers who care for the same patients. Designing around what patients actually need, rather than around how our organizations have always been structured, is the real work.

A Word to My Colleagues in EMS

Every EMS system is facing some version of this pressure, and every community will find its own answer. Some agencies have been doing IFT well for decades and have plenty to teach the rest of us. Others will find different paths that make more sense for them. IFT isn’t right for everyone. It takes honest capacity planning, real clinical governance, billing discipline and the willingness to say no when the emergency system needs you.

But I would encourage every leader to ask these questions:

Where does our responsibility to the patient actually end? Who is managing the clock after we leave? Are we sending the right response to the right patient? And are we willing to change, carefully and honestly, so we can keep serving our community well?

In my experience, the agencies that answer those questions honestly are the ones best positioned to mind the gap themselves, within their means and true to their mission.

I’m grateful to Shell Piercy and Bill Kinch for sharing these ideas and for showing that the challenges we face in a small American community look a lot like the ones being worked on in the Northern Territory and around the world. The future of emergency care, as Piercy writes, “will not be defined by any single discipline.” It will be built through collaboration.

The people who built EMS in this country never let boundaries stop them from caring for their communities. Honoring that legacy doesn’t mean protecting the lines they drew. It means doing what they always did: finding a way to take care of people when they need us.

Frequently Asked Questions

Why would a 9-1-1-only EMS agency add interfacility transport?

Because meeting 9-1-1 performance targets doesn't guarantee a sustainable budget. Interfacility transport adds scheduled, billable work that fits the EMS mission, helps hospitals move patients on time, protects 9-1-1 capacity and creates career paths for staff.

Does adding IFT take ambulances away from 9-1-1?

It shouldn't. IFT capacity should be planned around dedicated staffing time rather than hoped-for downtime, and if the emergency system needs a resource, the emergency system gets it.

What is a transition-of-care delay?

It's the delay a patient experiences moving between parts of the healthcare system, such as ambulance offload or wall time at the emergency department, waiting for an inpatient bed, or waiting for a discharge transport. These delays are connected indicators of a health system under pressure.

Why can't EMS agencies just recruit more volunteers?

Volunteers remain valuable, but in an economy where many families need two incomes, fewer people have time to give. Volunteerism is something to treasure. It isn't a funding plan.

Does moving EMS under a fire department or hospital solve the funding problem?

Every model has strengths, but changing who EMS reports to doesn't change what EMS costs or what it gets paid. The funding gap moves into another budget, where it's less visible to the public.

How can PSCG help an agency evaluate interfacility transport?

The Public Safety Consulting Group helps agencies assess capacity, governance, reimbursement and service-model options before adding a new service line. Call (203) 343-0433 or email info@thepscgroup.net.

Considering a new service line? PSCG works with municipal, fire-based and third-service EMS agencies on EMS system design, municipal EMS strategy and reimbursement optimization. Contact PSCG to start a conversation.

Michael A. Loiz is Chief Executive Officer of The Public Safety Consulting Group (PSCG), which has provided public-safety consultation, education, expert-witness services and system design since 2005. He also serves as a municipal EMS director, NAEMT Connecticut Advocacy Coordinator and chair of the Connecticut EMS Advisory Board Legislative Committee. Agencies weighing new service lines can reach PSCG at (203) 343-0433 or info@thepscgroup.net.

Inspired by Shell Piercy’s Beyond the Ambulance: Rethinking Emergency Care Through a Systems Lens and Bill Kinch’s presentation, The Waiting Room on Wheels: Managing Non-Emergency Patients, at the Bali 2026 Emergency Care Conference.