Ambulance Raises an Important Point About Ambulances

Michael Bay’s latest action-packed big-budget affair tells the story of a military veteran who steals millions of dollars from a bank in order to pay for medical bills. As part of their getaway, he and his partner-in-crime steal an ambulance, leading to a spectacular car chase through the streets of Los Angeles. The movie, released April 8, is straightforwardly titled Ambulance, and has so far proved to be a box office flop. But as researchers studying the ambulance industry, we’re less concerned with the artistic or monetary merits of the film, and more interested in the particular vehicle that it spotlights.

The ambulance used as the movie’s centerpiece bears a name familiar to many: Falck. Indeed, the movie feels like one long commercial for Falck Ambulance. A Falck-branded ambulance even made an appearance on the red carpet at the film’s premiere. Falck is a privately held company, with more than 3,000 patient transportation vehicles in 15 countries, owned by a number of different entities, including an investment company with ties to the toy manufacturer Lego. One key component of Falck’s business model involves cities and towns contracting 911 ambulance coverage to them. As part of these contracts, Falck provides a certain number of ambulances to respond to medical emergencies. It’s a vitally important job—and Falck doesn’t always meet expectations.

Alameda County, California, is very familiar with Falck’s business model. In 2019, Falck won the contract to provide ambulance service to Alameda County after promising ample staffing and response times of under 10 minutes for serious emergencies. However, the company’s performance has left both officials and residents unsatisfied. An investigation by a local news station found there were nearly 1,000 calls where Falck failed to meet the standard response time in December 2021 alone. Currently, Falck is under scrutiny in San Diego for not deploying enough ambulances to meet the needs of the city.

The private ambulance industry is big business, and Falck is not alone. A recent report projects the global ambulance industry will exceed $50 billion by the year 2026. Private ambulance services have proliferated, replacing city-owned or local-hospital-based ambulance agencies, with multistate conglomerates operating hundreds of trucks throughout a region. The largest of these conglomerates is Global Medical Response, or GMR. According to its website, GMR is responsible for 7,000 vehicles and nearly 500 aircraft that provide EMS services on six continents and respond to more than 10 million patients per year. Despite its size, GMR is a relatively young company, formed through a series of successive mergers between smaller medical transportation companies, culminating in a single privately held megacorporation. One of its owners is KKR, one of the largest private equity firms in the world and the onetime owners of R.J. Reynolds Tobacco.

There has been almost no quantitative research examining private ambulances. However, we can look to the experiences of communities that have been served by for-profit ambulance companies. Many do not have positive things to say about their experiences. Pflugerville, Texas, recently terminated its contract with Acadian Ambulance after just a few months; in a public meeting, residents complained of slow response times.* Colorado Springs, Colorado, has been in a multiyear battle with American Medical Response, a subsidiary of GMR, in pursuit of the response times that were originally promised.

We have some ideas about why these relationships have gone poorly. City-owned ambulances need to break even at best, and hospital-based ambulances are used as rolling advertisements, meaning bad publicity is like kryptonite. But for-profit ambulance companies have an incentive to maximize profit by limiting overhead as much as possible. This may involve staffing as few trucks as possible, leading to prolonged response times because there are not enough ambulances available to respond to calls. Minimizing overhead may also involve paying personnel as little as possible and minimizing benefits, despite working them as hard as possible and providing them with bare minimum levels of equipment. And it’s not just patients who suffer because ambulance companies have prioritized profit over performance. Emergency medical service providers themselves have exceedingly high rates of burnout and psychological illness. This may be one explanation for the nationwide shortage of EMS providers.

Other ambulance service models are not immune to short staffing or long response times, but greater local accountability and lessened profit motives historically have led to far fewer of the concerns seen with large private ambulance services. The performance of private ambulance companies warrants close scrutiny. There needs to be consumer awareness about the for-profit ambulance industry, and widespread recognition of who is actually providing ambulance services within a given community. This holds especially true when considering the fact that private ambulance companies often have an effective monopoly within a community. Community leaders and community members should be aware of the profit motives and incentives that may underlie the actions of for-profit ambulance companies. History indicates these profit motives have led many for-profit ambulance services to offer skimpy services. This brings us back to the movie Ambulance: The movie’s bank robbers use a private ambulance in an attempt to make off with a pile of money. That’s an apt metaphor for what the private ambulance business could be doing to all of us.