County briefing: EMS assessment finds staffing, data and funding reforms needed to stabilize ambulance service

Multnomah County received a formal briefing on an independent EMS system assessment that concluded the local ambulance system faces structural staffing and funding problems and that systemwide coordination and new financing models are needed. Aaron Monning, the county’s EMS administrator, told the Board that the assessment — based on interviews, ride‑alongs, field observation and data analysis — identified four core findings: a structural paramedic shortage, the need for stronger medical direction, siloed information systems, and a fragile funding model.

The assessment recommends a tiered staffing model that uses basic life support (BLS) and hybrid ambulances for lower‑acuity calls while deploying a focused pool of advanced care paramedics to critical incidents and rapid response vehicles. "The paramedic shortage is a structural reality," Monning said, recommending flexibility in how advanced clinicians arrive on scene so that clinical capacity is available for high‑acuity patients without requiring every response to be staffed identically.

The report also recommends creating a formal county office of the medical director with agency‑level medical directors who operationally report to a central county medical director to improve clinical oversight. Monning said the county currently has one responsible medical director and a stretched span of control across more than 2,000 active providers and nearly 100 licensed ambulances.

On data and operations, staff highlighted that dispatch, clinical charting and billing systems do not interoperate, which limits real‑time deployment decisions and complicates legal reporting and billing. The assessment recommends requiring interoperable systems that meet county standards or building a health information exchange to bridge existing vendor silos.

Financing was described as the most consequential policy choice. Monning said the county currently operates without a direct subsidy to the ambulance provider and that 77% of system users are on Medicare or Medicaid, which reimburse below cost. Options presented include enhancing fee‑for‑service, providing a public subsidy from the general fund, or creating a dedicated EMS service district with a stable taxing base. "We must move towards modernizing subsidies and funding the system as a public utility or a service district," Monning said.

Monning listed concrete next steps: Healthcare Strategies will assist drafting a revised Ambulance Service Plan (ASP) in May, a draft will be shared with the board in June or July, the ordinance process is expected in late 2026, and the plan would be implemented by Sept. 1, 2028 (the current AMR contract ends Aug. 31, 2028). Commissioners pressed staff on interim accountability, procurement levers to enforce response‑time performance, frontline staffing and retention, how the county would structure funding for first‑response partners, and how state rules and ongoing settlement work with the current provider intersect with the ASP process. Monning and staff committed to further work sessions and additional financial and operational analysis before the board adopts formal policy.