How ‘One big beautiful bill’ could break EMS

In this vital episode of EMS One-Stop, host Rob Lawrence is joined by Matt Zavadsky and attorney Doug Wolfberg of Page, Wolfberg & Wirth for a deep-dive into three financial flashpoints currently impacting EMS. First, the trio unpack the launch of the new PWW|AG/EMS|MC EMS Financial Index, a quarterly report leveraging billing and revenue cycle data from over 1,500 agencies nationwide. This unprecedented benchmarking tool allows EMS leaders to measure performance against regional and national trends, uncovering actionable insights into billing strategies, reimbursement rates, payer mixes and the economics of service delivery. It’s a critical step in helping agencies justify their value and improve their financial sustainability. Next, the discussion turns to MedPAC — the Medicare Payment Advisory Commission — and its controversial response to cost data submitted by ambulance services under the CMS Ground Ambulance Data Collection System. Doug Wolfberg explains how MedPAC discarded over half of the data, labeling higher-cost services — often rural or government-run — as outliers. This move could justify lower or stagnant Medicare fee increases, potentially devastating many providers. Finally, attention shifts to the “One Big Beautiful Bill” moving through Congress and now on its way to the Senate that would eliminate or severely restrict enhanced Medicaid funding mechanisms, such as supplemental payments and provider taxes. If passed, this legislation would reduce reimbursement for millions of transports, triggering funding crises across EMS systems — particularly in states like California and Illinois. The episode delivers a clear message: EMS leaders must prepare, advocate and act now. Episode timeline 00:41 – Rob introduces the three main topics: the PWW|AG/EMS|MC EMS Financial Index, MedPAC’s response to ambulance data and a major federal bill impacting Medicaid 01:59 – Part 1 — PWW|AG/EMS|MC Financial Index 03:37 – Matt explains that the index is built using data from over 1,500 EMS agencies via EMS|MC 05:43 – The importance of regional benchmarking 08:22 – First major finding: dramatic variation in ALS billing rates across regions 09:30 – Key insight: agencies that bill more tend to collect more revenue — agencies are encouraged to determine their true cost of service and align billing accordingly 12:37 – Collection percentage is debunked as a misleading metric; focus should be on dollars collected 15:36 – ALS vs. BLS billing levels explained, with a look ahead to Q2’s emergency-only data set 18:48 – How EMS agencies can better engage with insurers to cover non-transport and MIH services 20:46 – Part 2 — MedPAC 22:24 – Doug outlines how MedPAC discarded over half of the reported ambulance cost data 25:00 – Explanation of which data was discarded and why — primarily high-cost, rural and government-based services 28:22 – Doug asserts MedPAC is using cherry-picked data to suppress reimbursement increases 30:10 – Rob and Doug emphasize that EMS gave MedPAC quality input, but MedPAC is producing garbage output 32:08 – Doug outlines what MedPAC will do next and what EMS leaders must do in response 34:40 – Strong call to action: educate Congress, use real CMS data and don’t accept MedPAC’s narrative 36:59 – Doug emphasizes the importance of evidence-based deployment strategies for financial sustainability 37:31 – Part 3 — “One Big Beautiful Bill” 38:19 – Matt outlines how the bill would drastically limit Medicaid supplemental payments 39:43 – Federal/state Medicaid match rates explained with California as an example 42:51 – The looming reckoning: local governments may have to pay to maintain current EMS service levels 46:02 – Matt warns that the bill could trigger PAYGO cuts to Medicare as well 47:16 – Agencies are urged to plan now, talk to their communities and adjust operations 48:06 – Doug adds that pressure on U.S. senators, especially in red states, could still influence the bill 51:26 – Close and call to action Final takeaway This episode underscores that EMS cannot remain reactive — leaders must proactively use data, engage legislators and educate their communities on the true cost of care. The EMS Financial Index, the MedPAC dismissal, and the pending bill all point to a critical need for informed, strategic advocacy.