This page provides a detailed look at Linwood Ambulance’s future strategy as of the first quarter of 2025. We are making an effort to be very transparent about our current state and future vision so that all residents and visitors to our community have a thorough understanding of our organization and options for providing emergency medical services to our community.
– The Leadership & Board of Trustees of Linwood Ambulance
What does Linwood Ambulance do?
Linwood Ambulance provides a few key services to our communities:
- 911 emergency medical response for Lincoln & Woodstock on a 24x7x365 basis
- In-home medical care (called “mobile integrated health”) for the most at risk patients in our community
- Training and education, including community CPR and first aid classes as well as regional emergency medical technician (EMT) classes
- Maintenance of 70+ automated external defibrillators (AEDs) in Lincoln & Woodstock, supporting the community’s certification as a “heart safe community” by the American Heart Association
- Emergency response to assist other surrounding communities in cases where their emergency response systems are out of available resources. This is called “mutual aid” and occurs for example, when there are large fires or other emergencies in nearby towns.
How is Linwood Ambulance structured and who leads it?
Linwood Ambulance is a “doing business as” (dba) name of Linwood Medical Center, which is a non-profit 501(c)3 organization chartered with providing the above services. It is overseen by a volunteer board of trustees made up of experienced professionals from our local communities.
The service is led by a skilled team of emergency medical and management professionals. For example, our Chief, Jon Bouffard, is a long-standing paramedic with relevant advanced degress. He has experience servicing as a care provider and leader at organizations throughout New England.
You can learn more about our leadership and board at this page.
How is Linwood Ambulance staffed?
At all times (24x7x365), Linwood Ambulance staffs at least 2 trained and licensed medical providers for 911 emergency response. We make extensive efforts to assure that there is always a paramedic available (as either 1 of the 2 staff members, or on an on-call basis). Paramedics are able to provide advanced prehospital services including pain management, advanced airway management, and many extensive treatments similar to those available in a hospital emergency room.
If the 2 on duty providers are called to an emergency and a second or third emergency call is received, we rely on volunteers from our local community to come in from home to cover these calls. As a last resort, if no personnel are available or all resources are expended, we request assistance from surrounding towns (mutual aid).
Our on-call staff are generally paid a small stipend (well below minimum wage) for shifts and emergency calls. In addition to our on-call staff, we have 4 full time employees. Each of these employees is responsible for different duties for the service (e.g., personnel management, equipment and vehicle management, billing, finance, etc.). In addition to their office duties, our full time employees generally cover at least four 12-hour 911 shifts per week which overlaps with their office duty time.
How does Linwood Ambulance make money?
Currently, Linwood Ambulance has 3 primary sources of income:
- Reimbursement for ambulance services. When a patient is transported to the hospital, we are able to bill for these services. We bill insurance companies and then bill patients their balance of any patient responsibility. It is important to note that if we do not transport a patient, which is the case in approximately 40% of our calls, we are unable to bill for those services.
- Annual appropriations from Lincoln & Woodstock: In 2024, we received $125,000 each from the towns of Lincoln & Woodstock to support our service.
- Grants and donations: We are extremely proactive in pursuing government and private grants as well as charitable contributions to help support our service. It is important to note that in the vast majority of cases, money from these sources comes with stipulations on its use (e.g., it cannot be used to cover staff or day-to-day operating expenses). However, by receiving grants and donations, we lessen the reliance on taxpayers to subsidize services.
What challenges is Linwood Ambulance facing today?
Most critically, Linwood Ambulance is experiencing challenges staffing its 911 emergency response shifts. At any given time, the service must staff at least 2 trained and licensed medical providers, as detailed above. Many years ago, we found that it was possible to primarily staff these shifts with volunteers from within our communities. Today however, we find that our community members are less routinely available to staff these shifts due to personal and professional commitments – put another way, our members, however dedicated, often need to prioritize their paying jobs over staffing the ambulance. This shifts the burden of covering our critical 911 shifts to the full time paid staff, which often necessitates overtime pay, costing the service significant money.
Today, of the 2 providers required for a 911 shift, our statistics show that an average of 0.9 of these shifts (less than half) are covered by on-call members from our community.
To solve this, we recommend and plan to start paying our on-call staff to a reasonable hourly wage for 911 shifts (instead of a minimal stipend). In surveying our members, many have indicated that this would incentivize them sufficiently to fully cover the staffing gaps we experience.
How would Linwood Ambulance cover the costs of paying staff for on-call staff?
There are several methods the service is pursuing to cover the increase in staffing costs we anticipate:
- Increasing collections from ambulance billing: We recently switched billing companies and are performing extensive analysis to recover a higher percentage of our bills.
- Taking reasonable cost reduction measures while maintaining high quality: We are renegotiating some key contracts for recurring bills to save on our monthly costs while maintaining our ability to provide high quality care for patients.
- Seeking additional grants and charitable contributions: We are seeking ongoing grants and donations. However, as noted above, these funds often come with significant restrictions on their use.
- Asking for increased town appropriations: Though it’s never something we want to do, we are asking the towns of Lincoln & Woodstock for an increase in our annual appropriations to assure we can operate with a balanced budget. We note that if we are able to increase our income from any of the other above sources, we would decrease our appropriations request from the towns.
If the residents of Lincoln & Woodstock vote in favor of increasing appropriations, how do we know it will cover all the costs? Will there be future special assessments?
Our teams have performed extensive budget analysis and have many years of data to help forecast our anticipated budget needs. We are confident that our appropriations request is adequate to cover our annual operating budget, barring any significant changes in costs.
In addition, this budget already includes necessary costs for the replacement of our capital equipment. For example, ambulances as well as some of our key medical gear need to be replaced approximately every 10 years. An ambulance can cost $300,000 or more, and a patient monitor (a critical piece of our medical gear) costs $40,000 or more. Our proposed annual budget already includes contributions to a reserve fund that will cover the costs of replacement of these expensive items. Because of this, Linwood Ambulance is confident that its budget is comprehensive and includes sustainable funding well into the future.
If Linwood Ambulance moves to paying its on-call staff, who would work those shifts?
We plan to maintain our our existing roster of on-call staff from the community. Based on discussions with our members, we are confident that this increase in pay will result in our ability to fully staff our shifts.
Are Linwood’s Challenges Unique? Why has this happened?
The challenges faced by Linwood Ambulance unfortunately follow state-wide and national trends.
As recent Dartmouth study (1) found that:
- “[New Hampshire] is facing a critical shortage of EMS personnel […] compromising the system’s ability to adequately respond to health care emergencies“
And
- “EMS providers in New Hampshire receive insufficient pay and benefits to be incentivized to stay in their line of work. The vast majority of EMS personnel are volunteers, and it is challenging for these individuals to dedicate personal time and expense to serving their communities”
Further, these issues are felt nationally, where almost 70% of rural US EMS units have trouble meeting staffing needs. The study found that career change desires and pay are leading causes why staff leave EMS.
Additionally, there was a recent New York Times article (2) discussing ambulance services in upstate New York which describes similar challenges to those experienced in Lincoln & Woodstock.
(1) https://rockefeller.dartmouth.edu/report/ems-workforce-shortage-new-hampshire
(2) https://www.nytimes.com/2024/08/28/nyregion/ambulance-corps-volunteers.html
Will this result in a higher bill if I call 911?
It is incredibly important to us that ability to pay never impacts a patient’s willingness to call 911 or the care we provide. First, thanks to national laws such as the emergency medical treatment and active labor act (EMTALA), we must provide the same services to all patients regardless of their ability to pay. Second, we follow a billing schedule set by the State of New Hampshire that defines how we charge for our services. Third, it is our service’s policy that we do not send unpaid bills to collections if the patient resides in Lincoln or Woodstock.
What happens if appropriations for Linwood Ambulance are not passed?
If Linwood Ambulance is unable to balance its budget, it may eventually be forced to close. This would leave Lincoln & Woodstock without ambulance services if someone were to call 911.
What are the alternatives? Could a municipal service or private company provide ambulance services to Lincoln & Woodstock?
While there are alternatives to supporting the continued viability of Linwood Ambulance, the largely involve starting from scratch, and will forecast that these alternatively would ultimately cost our communities much more money while potentially providing lower quality of service.
Some other towns in New Hampshire have contracted ambulance services to private companies, many of which are for-profit entities. We estimate that to do this, the towns of Lincoln & Woodstock would need to pay a minimum of $750,000 to $1,000,000 per year for a single ambulance, as opposed to the 3 ambulances that Linwood Ambulance provides today. Further, a contracted ambulance may not provide services at nearly as high a training and certification level as Linwood Ambulance is able to provide. We expect that if a private company started providing services here and did not earn profits within the first year from insurance reimbursements, it would ask for more money from the towns in future years to continue providing services. We see this trend in other New Hampshire towns which are seeing degraded services for more money than they would pay from a local municipal or non-profit service. Further, a private service would not be incentivized (or often times eligible) to seek grants and donations to further enhance services to the community.
Alternatively, the towns could consider establishing municipal ambulance services, similar to or associated with the fire departments. While we believe this is preferable to contracting services to a for-profit entity, it would likely incur significant costs to the towns (potentially millions of dollars in the first year) to establish and begin providing these services – and it would likely incur very similar annual operating costs as Linwood Ambulance’s on a long-term basis. As such, we believe this would be far more expensive to taxpayers than continuing to support Linwood Ambulance.