The Future of EMS: A Reality Check and a Path Forward
It is time for a reality check in Emergency Medical Services (EMS). The word “emergency” has defined us for fifty years, yet it no longer captures the full scope of what EMS does. Think of it this way: imagine a national product that launched half a century ago and has carried the same name, the same logo, and the same marketing ever since. Over time, the world changed, the market changed, and consumer needs changed, but the brand stayed frozen. You cannot raise the price, expand the market, or grow the product because the public is fixated on what it was in 1974. If you engaged a modern marketing firm, their advice would be simple: change the logo, update the name, reframe the brand, and launch again with an identity that reflects today’s reality, not yesterday’s. EMS is in that exact position. We need a new identity that represents what we actually do: dynamic, integrated prehospital health care delivery that supports every corner of the health system.
EMS is the Green Beret of healthcare. A Green Beret operates in a small team with very focused skills and access to the most specialized resources. Their missions frequently take place in politically sensitive environments, demanding not only exceptional training but also cultural awareness and adaptability. Their work includes training, advising, and assisting local communities, often in unstable territory. They do not just fight battles; they build capacity, empower local communities, and create stability where none existed. In many ways, EMS functions the same way within healthcare. We manage chaotic environments with focused skills, advanced tools, and the ability to operate under intense pressure. We integrate into communities, teach, identify resources, and fill critical healthcare gaps. Yes, we are first responders, but at our best, we are healthcare providers who are force multipliers for the healthcare system. Yet, unlike the Green Beret, our identity and our systems are trapped in the past.
If we are to embrace that moniker, EMS must develop a path forward that allows the profession to grow and adapt to the realities of modern healthcare. To do that, we must first recognize the barriers holding us back. This is by no means a complete account of the complexities of the EMS industry, but instead a thought exercise to identify some of the more significant structural barriers.
One of the most pressing is professional structure. The National Registry of EMTs was founded with a clear mission: to ensure competency. In this, it has succeeded, creating a respected system of professionally managed exams. Unfortunately, NREMT has also become a barrier that drives providers out of the workforce. Nurses and physicians take a national board exam once and never interact with the initial licensure process again. Sure, some providers may take specialty board exams which require periodic recertification, but this is comparable in structure to FP-C or CCP-C. EMS providers, however, must either retest or provide evidence of continuing education documentation to renew their Registry certification every two years. This requires a service affiliation and medical director sign-off, creating obstacles for those between jobs, those who transition into adjacent healthcare roles, or those who step away temporarily. While the Registry does offer an inactive status, the additional requirements to reactivate are another hoop that discourages capable providers from returning. How many competent professionals have we lost because of this system? Provider-level exams should be taken once, and licensure should be regulated by the states, as it is for every other healthcare profession. Moving oversight to the states would align EMS with the rest of healthcare and reduce unnecessary attrition. The ground work for this is in place. The EMS Compact has been created that allows movement of EMS professionals across state lines and twenty-five states have now joined. Not only does it provide for easier movement between states, it also provides a framework for professional oversight.
Professional pathways are another area in urgent need of reform. For decades, EMS has treated EMT as the mandatory entry point to the profession, largely because EMTs came first and paramedics grew out of that structure. But tradition is not justification. CNA is not required for nursing, nor is LPN for RN. Both exist as valuable options, but neither is mandatory. EMT should likewise stand on its own as an important but optional credential. The paramedic should be a professional entry point, supported by degree-based pathways that elevate the role as a clinical profession. Australia has already shown the way, and while their context differs, the model is transferable (Williams et al., 2016). To do this, we must have a strong enough workforce to support the growth in academic expectations. This will not happen overnight, but it will never happen if do not develop that as a long term goal.
Federal oversight presents another challenge. EMS was born in the late 1960s and early 1970s under the umbrella of what became the National Highway Traffic Safety Administration. That origin made sense in a time when the profession was still closely tied to motor vehicle trauma. But more than fifty years later, why are we still regulated from that agency? Other healthcare professions are not governed by federal agencies, and neither should EMS. National guidance is valuable, but the future of EMS must be driven by providers and operators, not distant bureaucracies with little insight into local realities. Progress will require unifying our voice through professional associations, interstate compacts, and collaborative leadership. At the same time, we must re-examine how EMS is organized at the state level. In most states, provider licensure and industry regulation are housed within the same agency. That arrangement stifles professional growth. Imagine if nurses or physicians were regulated by the same office that governed hospitals; professional representation would be impossible. EMS needs independent structures that allow the professionals to advocate for themselves and the industry to be regulated separately.
Structural issues aside, the greatest anchor holding EMS in place is reimbursement. Our current model is still built on a freight system: a base rate and mileage. We are paid to move patients, not to deliver care. Hospitals and physicians are rewarded for improving quality, reducing unnecessary admissions, and achieving better outcomes. EMS is rewarded for the number of transports completed, regardless of whether that trip actually improved health. Here is a hard fact: we are paid the same for substandard care as we are for exceptional care. How can that possibly incentivize improvement? It is nearly impossible to build a future on such an antiquated foundation. No other sector of healthcare is expected to grow without a viable payment pathway, yet EMS has been asked to do just that. EMS has the potential to do so much more than responding and transporting patients, but we need a financially stable reimbursement structure that rewards quality and innovation.
There has been some movement in the right direction. The CMS Emergency Triage, Treat, and Transport (ET3) pilot created a path for reimbursing treatment in place and transport to alternative destinations, though it collapsed under COVID. Community paramedicine programs have demonstrated reductions in emergency department utilization and hospital readmissions, while improving patient satisfaction. But these efforts remain fragmented, champion-dependent, and rarely backed by sustainable funding. Until reimbursement reforms are enacted on a broad scale, EMS will continue to lag behind the rest of healthcare (National EMS Advisory Council, 2019; Commonwealth Fund, 2022).
The mindset shift is clear. EMS must stop defining itself solely by emergency response and start embracing its role as the Green Berets of medicine. We should be educators, advocates, and healthcare navigators, force multipliers, connecting patients to the right resources at the right time. Our scope must expand beyond 911 response to chronic care management, public health partnerships, and integration into primary care. The future of healthcare is being shaped by artificial intelligence, telehealth, and data-driven care coordination. EMS cannot afford to be a bystander. We must adopt these tools early, adapt them to prehospital realities, and prove our value as an indispensable part of the healthcare continuum.
The opportunity is in front of us, but seizing it will not happen by accident. It will require a new identity, new structures, new reimbursement, and new professional pathways. Most importantly, it will require us to see ourselves not just as responders to emergencies but as full participants in healthcare delivery. If we fail to make that leap, we will remain mired in the past. If we succeed, EMS will finally claim its rightful place as healthcare professionals.
References
Commonwealth Fund. (2022). Promote use of community paramedicine. Profiles of cost containment strategies. https://www.commonwealthfund.org/sites/default/files/2022-02/Hwang_health_care_cost_growth_strategy_08_paramedicine.pdf
National EMS Advisory Council. (2019). EMS system performance-based funding and reimbursement model. EMS.gov. https://www.ems.gov/assets/NEMSAC_Advisory_EMS_System_Funding_Reimbursement_Sep_2019.pdf
Williams, B., Onsman, A., & Brown, T. (2016). From stretcher-bearer to paramedic: The Australian paramedics’ move towards professionalisation. Journal of Emergency Primary Health Care, 14(1), 1-9.