Cory, a 26-year-old emergency medical services professional, had been working in southern California for several years when he started seeing teal ambulances, emblazoned with the words “Ambulnz,” zipping around Los Angeles. Founded in 2015, Ambulnz transplanted the push-button ride hailing model to non-emergency medical transport, offering on-demand patient transport services for hospitals and other care providers. The majority of Ambulnz business involves moving patients from hospitals to their homes, or transferring patients between medical facilities. This type of service is called interfacility transfer, or IFT.
Cory, who requested anonymity for this piece, was enrolled in paramedic school at the time. He needed a part-time gig to complete his internship so he could simultaneously complete his paramedic classes, and the Ambulnz gig fit into his schedule.
After applying and interviewing with Ambulnz, Cory received an offer, and went to the company’s office in Carson, California, for orientation. The office, he remembers, was “pretty legit” and “very modern looking.” It reminded him of an Apple Store. There was an employee break room with snacks.
But his experience with Ambulnz quickly soured. Cory says that in his orientation class of approximately 32 people, most new employees seemed “socially awkward, or flat out weird, as if they were turned down by every other ambulance company.” He says one new hire told him that his only serious prior work experience was 12 years as a seasonal Halloween scare actor at Universal Studios. As part of the orientation, Cory says, the class FaceTimed with Ambulnz CEO Stan Vashovsky, who bragged about the company. “It was awkward,” he recalls.
Though he says he’d been told in his job interview that he’d be paid $16 per hour, at the orientation that rate dropped to $12. Then Ambulnz told him the station he’d be working at had changed to a location one hour further from his home. After 20 minutes as an Ambulnz employee, Cory quit. He signed a voluntary resignation form, received a check for four hours of work, and went home.
Cory is one of several Emergency Medical Service professionals interviewed by OneZero who cast doubts on the promise of Ambulnz. Former employees say they were overworked, and under-resourced. The company encourages some emergency medical technicians (EMTs) to take on sales responsibilities, meaning that their compensation is dependent on the revenue they generate. Across EMS communities (which are largely comprised of Emergency Medical Technicians, or EMTs, and paramedics), the company has become the target of jokes, memes, and disdain. While some of the criticism stems from the company’s startup-casual branding and marketing, EMS professionals have material complaints too. To some, Ambulnz epitomizes larger problems within their industry — in particular, the trend toward privatization.
“The private ownership model for ambulances is fundamentally at odds with its own purpose,” a former volunteer EMT named David Anderson wrote in the policy magazine Current Affairs last year. Anderson described an environment in which EMTs are “pulling 60-hour workweeks to scrounge together a rent check.” The low wages, irregular schedules, and exhausting conditions lead workers to burnout within two years. Some of those conditions, Anderson argued, are the result of private companies overworking and underpaying their employees.
“If you’ve spent any amount of time on the internet EMS community, you’ll know we aren’t fans of private ambulance companies,” says Derek, an EMT who works for an IFT rig in California who requested anonymity for this piece. “In short, they normalize the concept of EMS as a private business.”
“A private corporation’s only goal is to make profit,” he adds. “A public service exists to serve the people,” he says. Companies like Ambulnz, according to some EMTs, make this distinction clear.
With their friendly, teal-colored Sprinter vans and Ford Transit vans, Ambulnzs have popped up in cities across the country over the last few years, from New York to Nashville to Los Angeles. Ambulnz operates ambulances as well as ambulettes, which feature fewer medical capabilities, and don’t respond to 911 calls. Instead, these vehicles are used to move patients between hospital facilities, or back and forth from appointments, such as dialysis or radiation treatment.
Private ambulance and medical transport companies have been around for decades, though the industry has seen renewed interest over the last decade. A 2016 New York Times investigation revealed that, since the global financial crisis, private equity firms “have increasingly taken over a wide array of civic and financial services that are central to American life.” That includes emergency medical services: As of 2017, 18% of all ambulance service companies are privately operated.
It’s estimated that market demand for EMS services will increase by 7% from 2018 to 2028, driven by the needs of the aging Boomer generation. For the private medical transport industry, this increasingly sick population represents a significant financial opportunity.
Ambulnz was founded in 2015 by Stan Vashovsky, a health care entrepreneur and former executive at Philips Medcare. The company received two investments of undisclosed amounts: one from London-based Hillview Group, and a second from Chicago-based Valor Equity Partners. Ambulnz, as described on its website, is “revolutionizing the industry in efficiency.” Since 2015, the company has acquired several private ambulance operators in Los Angeles County, New York, and overseas in Manchester, U.K. The company has also partnered with Uber Health in a deal that allows Uber sedans and Ambulnz vehicles to appear in the same app for healthcare providers. Earlier this year, Axios reported that Ambulnz was seeking $90 million in funding.
In an interview with OneZero, Vashovsky confirmed details of Ambulnz’s business model and future ambitions. Today, he said, Ambulnz is focused on interfacility transfers, highlighting the company’s push-to-request dispatch system as an improvement over typical dispatch systems, which usually require phone calls.
Vashovsky avoids broader comparisons to Uber and Lyft because those companies generate revenue on business to consumer models (B2C) rather than Ambulnz’s business to business model (B2B). Still, Vashovsky indicated that his company was looking for ways to “be more B2C,” laying out a vision for a “very efficient workforce” of field EMTs offering care to patients in their homes, using telehealth tools to communicate with doctors.
Ambulnz differentiates itself from traditional interfacility transfer companies by its employment and business models. The company’s recruitment language mirrors that of gig-economy employers, touting a system that rewards raw efficiency. The model promises EMTs a “flexible schedule” and “a path to entrepreneurship.”
In a 2018 blog post, Vashovsky claimed it’s possible to “save” EMS workers by “liberating and revolutionizing the EMS system — increasing wages, offering EMTs more flexibility as 1099 employees rather then [sic] full-time W2 employees, and by implementing new technologies that will alleviate high-volume pain points and deliver better quality care to patients.”
Vashovsky confirmed to OneZero that the company is currently using 1099 employees in small pilot programs in the states where it’s allowed. Otherwise, the majority of Ambulnz’s workforce is made up of W2 employees.
Ambulnz also touts its digital dispatch system as a market differentiator. Typical IFT dispatch systems require health care providers to call human dispatchers, who then use a computer-aided dispatch system (CAD) to send out an ambulance. Ambulnz aims to automate the process, allowing providers to request a vehicle directly via the Ambulnz app. Meanwhile Ambulnz dispatchers, Vashovsky told OneZero, focus on tackling “anomalies” rather than individual requests. Vashovsky also said Ambulnz was preparing a pilot program with a hospital system that will allow them to “lease” Ambulnz dispatch technology without using Ambulnz vehicles.
Ambulnz is not the first company to conceive of ambulances dispatched from apps, but it may be among the largest of such efforts. In 2011, a company called Stat, described as “Uber for medical transport” by TechCrunch, developed a service which routes idle ambulances to requesting providers and hospitals. Unlike Ambulnz, Stat did not have its own vehicles or EMTs, making it a truly Uber-like service. Stat, according to a 2018 Medium post from its CEO, appears to have shut down five years ago.
Though Ambulnz says it “exists to improve the lives of EMTs,” EMTs who spoke to OneZero were skeptical of its promises. Emergency medical service is dangerous and grueling work. It’s also poorly paid: many paramedics and EMTs take multiple jobs to make a living. As noted in a 2018 Money story, the median pay for EMT and paramedics is $16.50 per hour ($34,320 per year), or “about 40% less than the average employed American earns, [making it] one of the worst-paying medical jobs out there.”
Amy Eisenhauer has been an EMT since 1995, and advocates for providers as a regular EMS conference speaker and writer. She notes that IFT work can be rewarding, but admits that often “[IFT providers] try to push in as many calls as possible, because they need to make money, to keep the doors open, and so sometimes that becomes money-making is the key, not necessarily doing the right thing.”
“We entrust our loved ones into their care, but pay them like they’re flipping burgers.”
Private IFT services like Ambulnz often pay less than their public counterparts. Saba Waheed, research director at the UCLA Labor Center, co-authored an extensive paper detailing the wage and working conditions of emergency medical services in California. The paper notes that private ambulance companies “minimize capital and labor intensity of operations, often with adverse impacts to workers.” In an interview with OneZero, Waheed said, “in the private workforce, [EMTs] make 40% less than the public sector, [and] the median wage has fallen 12%, between 2007 and 2013. Workers are tending to be more part-time and part-year. So everything has been signaling a decline in the job quality and wages.”
In its informational videos, Ambulnz tries to capitalize on the industry’s poor compensation. “EMTs make a fraction more than minimum wage,” says the narrator in a 2017 video by Ambulnz. “We entrust our loved ones into their care, but pay them like they’re flipping burgers.”
The company often cites the opportunity for EMTs to make up to $72,000 with Ambulnz. “At my old job, I was making pennies. Peanuts. Here at Ambulnz, I’m making filet mignon,” says one unnamed Ambulnz EMT in a promotional YouTube video.
The company runs optional incentive programs — called “model programs.” EMTs who enroll in the program are paid in part based on the number of calls they respond to, and in some markets, when model EMTs are not running calls, they are trained to “act as sales associates.” The different incentive programs are based on revenue, customer satisfaction, and on-time performance, says Vashovsky. These EMTs are encouraged to stop by different outpatient centers, such as nursing homes, to introduce themselves, explain Ambulnz, and drop off a business card. The model programs vary from state to state, in order to comply with the laws and conditions of that specific market, according to the company’s CEO.
An Ambulnz EMT who worked for the company in 2017 credits the model program for giving him “an idea of how to be an entrepreneur,” he told OneZero. The employee claimed to have exceeded $72,000 in his first year’s salary. Vashovsky said he could not discuss the specifics of compensation, as the company considers that part of Ambulnz’s corporate intellectual property, and a competitive differentiator.
Other former Ambulnz employees were more critical of the company’s incentive programs. Reviews on Glassdoor indicate that EMTs who sign up for the model program and do not meet the minimum of number of six calls per shift receive a base hourly rate at or near minimum wage. Based on 18 reviews, average total pay as an Ambulnz EMT is $28,000 per year.
Paul, who requested anonymity so he could speak freely of his experience, is a former Ambulnz dispatcher. In the recruiting materials, Paul said the company marketed itself “like Uber for ambulances.”
Despite being on the East Coast, Paul dispatched Ambulnz vehicles on the West Coast, which he said was “incredibly disorienting.” He eventually quit, frustrated by his schedule changes, and “constantly having to educate ourselves about California labor law and EMS protocol because nobody trained us properly.” He says teams were grossly overworked, with over 30 dispatch assignments sometimes split between just two ambulances. Complaints from patients, providers, and overworked EMTs were common. “I wouldn’t trust them as medical providers at all,” he says of Ambulnz.
EMTs are encouraged to stop by different outpatient centers, such as nursing homes, to introduce themselves, explain Ambulnz, and drop off a business card.
UCLA Labor Center’s Waheed was also suspicious of Ambulnz’s claims that EMTs stand to make $72,000 per year with the company. In response to that figure, Waheed says, “Our data doesn’t show [wages] anywhere near that.”
“If they are actually able to provide that for a full-time worker, that’s awesome, because these are very important jobs, and they deserve to be compensated well,” Waheed says. “I would want to ensure that 72 [thousand] comes from a place where you’re not driving this person into the ground.”
David Fifer, a paramedic and assistant professor at Eastern Kentucky University’s Emergency Medical Care program, says that Ambulnz fulfills a need in the United States, as “many parts of the country are underserved by ambulances in general,” but he also has concerns with Ambulnz’s fundamental model.
“It’s [sic] seems like there’s a moral hazard that needs to be addressed: an employee who earns more money the more transports they conduct might see an incentive to cut corners, falsify patient care records, or even drive recklessly,” he says. “Pay for performance models aren’t inherently bad, but they require a strong culture of excellence and strong quality assurance metrics to ensure performance means more than just volume.”
In its report earlier this year, Axios noted that Ambulnz’s business prospects are uncertain, stating that it has a “high cost, narrow purpose,” and there are more affordable options coming online. For example, both Uber and Lyft stated they will be pursuing seniors with Medicare Advantage (MA) plans after the Centers for Medicare and Medicaid Services (CMS) announced additional MA benefits for 2020. Patricia Pittman, a professor of health policy and management at Milken Institute School of Public Health at the George Washington University, as well as the director of Fitzhugh Mullan Institute for Health Workforce Equity, says there is a movement for ambulance services to integrate into larger health systems, such as Accountable Care Organizations, which seek to maximize positive health outcomes instead of optimizing for billing.
“Most stand-alone ambulance services have the opposite interest: increasing trips to the hospital,” says Pittman.
If there’s one thing observers can agree on it’s that the emergency medical service needs an overhaul: EMTs need higher pay, better career opportunities, affordable benefits, and less grueling schedules. As aging populations increase, these needs will only become more apparent. Unfortunately, Ambulnz, a company focused on commoditizing and optimizing an already precarious workforce, is not likely to alleviate these issues.