There’s an increasingly urgent need for more state-funded ambulance units across the state to deal with a surge in emergency calls, primarily by seniors and the homeless, emergency services chiefs told state lawmakers last week.

One new 24-hour ambulance is needed on each of three islands — Kauai, Hawaii island and Oahu — emergency medical services officials told a joint hearing of the Senate Commerce, Consumer Protection and Health and the House Health and Human Services committees on Tuesday.

Requests for new ambulance units for Kauai and Hawaii island were nixed late in last year’s legislative session.

“That need doesn’t go away just because it wasn’t approved last year,” said Dr. Libby Char, an emergency room physician and chairwoman of the Emergency Medical Services Advisory Committee.

Meanwhile the urgency for additional service has increased on Oahu, said Char, a former Honolulu emergency medical services director. To fund all three would cost roughly $5 million annually.

“This is not a new project,” she said. “This is keeping up with current needs as things evolve and change.” Not doing so will mean “a further degradation of the EMS system, and at some point lives will be lost,” she said.

Jim Howe, Honolulu emergency services director, called his operations “really significantly strained.”

Because of the increase in response volume, response times have grown longer.

“If we don’t do something, lives will be lost,” Howe said. “The continuing calls are really just burning out our people, and they’re burning up our ambulances, literally. They’re running 24/7.”

The state Department of Health holds contracts with each of the four counties to provide emergency transport and care services. Funding for the three additional ambulances is not in Gov. David Ige’s budget, but the EMS chiefs are hopeful they can get it through the Legislature this year.

Dan Galanis, epidemiologist for the Health Department’s EMS and Injury Prevention Branch, presented data showing EMS responses going up about 3 percent annually since 2012, or about 4,400 more each year.

Data show that during the same time, EMS responses for older patients accelerated at a quicker pace. Of patients who required transport or who died last year, 41.7 percent were 65 or older, up from 37.4 percent in 2012.

The number of homeless patients has also gone up at a faster rate, Galanis said. In 2016, 9,298 patients were homeless and made up 8.5 percent of the statewide number of EMS records. That was up from 2012, when 6,147 homeless patients made up 6.2 percent of EMS records.

Data show the homeless made up only 2.2 percent of individual patients from 2012 to 2016 but 7.6 percent of all encounters, which means they have a higher frequency of repeat calls.

More than half of the homeless patients who received service, 54.2 percent, had more than one encounter. Among those receiving calls who are not homeless, only 21.6 percent had more than one encounter.

Hawaii County, through its Fire Department, operates 15 ambulances. The Honolulu Emergency Services Department deploys 18 24-hour ambulances and two part-time ones. Maui and Kauai counties employ the serv­ices of the private AMR Hawaii, which uses 10 ambulances on Maui and five on Kauai.

The EMS community also wants to see changes in the law that now allows reimbursement for services only if patients are transported to a hospital emergency room with one exception: the Waianae Coast Comprehensive Health Center, said Dr. Alvin Bronstein, statewide EMS branch chief for the Health Department. The state can’t be reimbursed if the ambulance call ends up with a patient either refusing transport or given a ride to a clinic, urgent-care facility or other place they can receive medical attention, he said.

“I think we can get very creative, but we need to be able to bill for nontransport, and we need to be able to bill even if we do transport someone to a clinic,” he said.

“If we go to a scene and the patient refuses to go to the hospital or refuses transport, we can’t bill for those patients, so that’s lost time,” Bronstein said. Additionally, “if we go to someone’s house or their location and we render care, we have no mechanism … to bill.”

“The question then, in the 21st century, is, How do we pay for someone to go out and maybe even provide some care but there’s no reimbursement?” Bronstein asked. “Not all people need to go to an emergency room.”

Galanis’ data show the number of responses that required treatment but did not result in transports has doubled since 2012. They now account for 14 percent of responses, up from 8 percent in 2012, he said.

The counties want to set up mobile clinics to divert nonemergency calls in order to free up ambulances for those who need them, but the inability to charge for such services makes it financially difficult to sustain, Bronstein said.

Hawaii County has a federal grant that subsidizes a community paramedic program. Honolulu initiated a pilot program in November 2012 but discontinued it, citing staff shortages.

Howe said such programs would help with both his department’s homeless and senior patients who don’t need to go to the hospital.

Honolulu has 16 vacancies among paramedic and emergency medical technicians out of 250 positions.