HomeMy WebLinkAboutMinutes - July 2, 2002 SSCITY OF LODI
INFORMAL INFORMATIONAL MEETING
"SHIRTSLEEVE" SESSION
CARNEGIE FORUM, 305 WEST PINE STREET
TUESDAY, JULY 2, 2002
An Informal Informational Meeting ("Shirtsleeve" Session) of the Lodi City Council was held Tuesday,
July 2, 2002 commencing at 7:01 a.m.
A. ROLL CALL
Present: Council Members — Hitchcock, Land, Nakanishi (arrived at 7:04 a.m.), and
Mayor Pennino
Absent: Council Members — Howard
Also Present: City Manager Flynn, City Attorney Hays, and City Clerk Blackston
B. CITY COUNCIL CALENDAR UPDATE
City Clerk Blackston reviewed the weekly calendar (filed).
C. TOPIC(S)
C-1 "Paramedic Program Update"
Fire Chief Pretz reported that the goal of the paramedic program is to enhance the
delivery of emergency medical services to the City of Lodi. Records from the California
Department of Finance indicate that since 1995 to present the population in Lodi has
increased from 53,100 to 59,400. The response times from San Joaquin County
Emergency Medical Services (EMS) Agency have increased 35%, from 3.94 minutes in
1996 to 5.31 minutes. The number of transports has increased by 72% since 1996. In
1995 American Medical Response (AMR) had three ambulances in Lodi. In 2000 the
ambulances were decreased to two and they were also used to do inter -facility transports
in and out of the City. During a six-week period between February and March 2002 there
were 20 incidences where only one ambulance was in Lodi; between May 1 through 20,
2002 there were six such incidences; and eight incidences have occurred where there
were no ambulances available.
Chief Pretz recalled that when this topic was discussed in January, Council directed staff
to refine the cost and revenue estimates, investigate public/private partnerships, develop
options, and report back to Council. Chief Pretz reviewed the following options:
➢ Make no changes.
➢ Support additional private providers to enhance the number of ambulances on the
street. Chief Pretz stated that competition may lead to lower prices and better service
delivery for citizens. Lodi's zone is in a nonexclusive jurisdiction, which means that
other ambulance companies who meet requirements can provide services to the
community. Chief Pretz reported that three other providers have expressed an
interest in providing ambulance services to Lodi.
➢ Provide a fire -based EMS system. Chief Pretz believed that this option would
enhance the local emergency medical delivery system. He explained that it is
effective because multi -role firefighters provide a stable, dependable workforce. He
noted that cost can be offset by revenues.
➢ Partner with private providers, i.e. the Fire Department would provide Advanced Life
Support (ALS) service for a private provider who would handle transport service.
Chief Pretz stated that his investigations indicate that there would be offsetting costs
to provide this program.
Enter into a third service partnership, i.e. with a locally -owned nonprofit organization
composed of concerned citizens and local business owners. Chief Pretz explained
that the nonprofit organization would be able to recoup cost, share revenue, and meet
the needs of the community, because the board of directors in this scenario is the
community. It could be operated with lower costs, which would be passed on to the
Continued July 2, 2002
consumer. Revenue would stay in the community and be used to enhance the
system.
Council Member Nakanishi disagreed with Chief Pretz's statement that competition leads
to lower prices. He stated that medical economics show that more availability will
increase costs.
Chief Pretz remarked that private providers do not want government interference in
entering into the market; however, once they are established, they immediately ask for
protection, which creates a monopoly.
Council Member Nakanishi stated that he is supportive of the Fire Department and is
against privatization. He expressed concern about health insurance and uncompensated
care issues.
Chief Pretz asked Council whether the Fire Department should be allowed to provide
paramedic service to the City of Lodi and if so, whether the department should undertake
transport as a way to offset costs. Chief Pretz noted that he had previously
recommended seeking a consultant; however, he stated that he is capable of making a
recommendation to Council on this issue.
In answer to questions posed by Council Member Land, Chief Pretz reviewed his
background and experience in managing a fire department, which provided both
advanced and basic life support services. In reference to response times, Chief Pretz
reported that the Fire Department reaches the scene first 65% of the time and in 35% of
the incidences it is either a tie or AMR reaches the scene first. He stated that if the
proposed program were instituted immediately, the Fire Department would need to hire 12
new firefighters, and eventually a total of 15 new firefighters would be needed to cover for
vacations, sick leave, etc. Chief Pretz reported that the County requires EMS to respond
to calls within eight minutes or less. The Lodi Fire Department is successful 86% of the
time in reaching the City's goal of arriving within five minutes or less.
Council Member Land outlined his concept for a five-year business plan. In year one the
Fire Department would have an ambulance and paramedics. In year two if AMR did not
reach certain benchmarks (e.g. decreased response time) then a second ambulance
would be added to the Fire Department. This would continue in subsequent years until
benchmarks were reached.
Chief Pretz was unsure whether the City could tighten response time standards that are
set by the County. He offered that perhaps the City could use call volume as a
benchmark. He reported that a draft two-tiered plan has been developed, in which
paramedics would first be placed at engine companies, and in the second tier the
transport system would be instituted. Chief Pretz confirmed that 70% of calls received in
the Fire Department are emergency medical calls, and of those, 65% of the time, the Fire
Department arrives on the scene first.
City Manager Flynn believed that providing paramedic and transport service would benefit
morale of the Fire Department staff. He noted that the private provider is meeting the
standards set by the County; however, it may not be providing the level of service that
Council desires for the citizens of Lodi. He estimated that the Fire Department's
proposed program will cost $1,500,000 annually at full operation. He noted that another
option Council could consider is contracting with the private sector to provide a higher
level of service and compare what that would cost to the Fire Department's proposal.
In reply to Mayor Pro Tempore Hitchcock, Chief Pretz reported that morbidity figures go
up considerably after six minutes from certain conditions, such as heart attacks.
Chief Pretz stated that National Fire Protection Association (NFPA) 1710 will soon be
requiring for ALS services, that fire departments assemble a four -person team consisting
of two paramedics and two emergency medical technicians. In addition, private providers
will have to meet the same response time criteria as a fire department. Chief Pretz
2
Continued July 2, 2002
reported that Lodi is currently classified as a Class 3 city and indicated that insurance
costs could be reduced if the number of fire department personnel were increased and
paramedics were added to engine companies.
In response to Mayor Pro Tempore Hitchcock, Chief Pretz stated that the City of Stockton
believed that additional ambulances should be available in the city and gave permission to
their fire department to purchase up to ten additional ambulances. They intend initially to
operate five additional ambulances in the core area of the city where they have the most
demand.
PUBLIC COMMENTS:
James Sepiol introduced himself as the Medical Director of Sierra Occupational
Services at Dameron Hospital and noted that he is Board Certified in emergency
medicine.
Council Member Nakanishi asked Dr. Sepiol if he believed the trend of non-
emergency, uninsured patients coming to emergency rooms for treatment, is
increasing.
Dr. Sepiol stated that since he began practice in Stockton in 1979 he has not seen a
significant increase in the number of patients; however, there are less and less
people that are insured.
Council Member Nakanishi stated that while in Los Angeles last week he read an
article, which reported that many private hospitals in the area were closing their
emergency rooms. Ambulances in the Los Angeles area are often stacked side by
side with long waits. The article also reported that the indigent, and people from
Central America, are being told to go to emergency rooms for treatment. He
expressed concern about the financial condition of Lodi Memorial Hospital and
potential unintended consequences of the Fire Department's proposal. He reported
that he spoke with Joe Harrington, Chief Executive Officer, yesterday who stated that
the hospital cannot take more ambulances in its emergency room. Mr. Nakanishi
recommended that a two by two committee of Council and Lodi Memorial Hospital
representatives be created to discuss this matter before action is taken.
Dr. Sepiol acknowledged that emergency rooms in Stockton close to emergency
transport at times due to the unavailability of beds in the intensive and critical care
units. This creates a "round robin" situation for the ambulances. Dr. Sepiol did not
believe that increased utilization of ambulances would make an impact in Lodi
because there is a finite population going to one hospital.
Council Member Nakanishi stated that Lodi Memorial Hospital has seen an increase
from 17% to 19% in uncompensated care. Ambulance service has increased from
12% to 13%. He believed that more ambulances would increase the problem of
patients using the emergency room for non -emergency situations. He suggested that
a decision be delayed to allow time to evaluate the impact and quality of care issues
resulting from changes that have recently been instituted in Stockton.
In answer to Council inquiries, Dr. Sepiol expressed his opinion that response times
in Lodi are adequate. As the first responder in Lodi is usually the Fire Department,
care is begun at the time they arrive. He did not believe that communication between
medical personnel was an issue to be concerned about because it routinely takes
place once patients arrive at the hospital; however, continuity of care is optimum.
• Walter Mayer referred to a statement by AMR (filed) and noted that he was billed for
15 miles, when he was actually transported a distance of only 1 mile. He brought this
error to AMR's attention; however, for five years he alleged that he was ignored. On
February 13, 2002 the billing error was corrected. He expressed appreciation to the
Lodi Fire Department personnel who saved his life and commented that AMR came
two minutes after firefighters arrived and transported him to the hospital for $725.
Continued July 2, 2002
Sandy Wichman, President of the Lodi Professional Firefighters Local 1225, of the
International Association of Firefighters, clarified that this issue is about who will
provide the best service to the citizens of Lodi. He stated that Lodi firefighters have
been providing outstanding service to the community for many years and most
citizens are under the impression that they provide paramedic transport. He asked
Council to consider their loved ones and whether they would rather wait 20 minutes
for an ambulance to respond from Stockton or have the Lodi Fire Department
respond.
• Peter Iturraran, Vice President of Local 1225, challenged the Mayor to provide the
best EMS program for the citizens of Lodi and urged Council to approve the Chief's
recommendations.
Lou Meyer, Chief Executive Officer for AMR's Northern Pacific Region, reported that
AMR has serviced the Lodi community for over 30 years. AMR has met the
standards of care required and have also offered to enhance the first response level
of service through a public/private partnership with the Fire Department. He believed
the only enhancement to Lodi's service would be to train and upgrade its personnel to
the paramedic level. He stated that Chief Pretz distributed a solicitation for an
informal Request for Proposals (RFP). Subsequent to reviewing the RFP, Mr. Meyer
urged Council to direct the City Attorney to research EMS laws, profit sharing
scenarios, and the federal anti -kickback statutes prior to making a decision. He
stated that even the public/private partnership that AMR offered would have to be
done through certain regulations at the County level and if there is more than one
ambulance provider in the community it becomes very complex. In reference to
Walter Mayer's complaint, Mr. Meyer explained that due to a keystroke error, 1.5
miles was billed as 15 miles. The improper mileage amount was refunded to
Medicare and Mr. Mayer's secondary insurance carrier.
Council Member Land recalled that two years ago Battalion Chief Steve Raddigan
had to negotiate with AMR to keep one ambulance in the City after 8:00 p.m.
Mr. Meyer reported that a deployment system is approved by County officials. There
are times when multiple calls are coming in at one time and deployment patterns are
used to cover from Stockton. He stated that units are not moved from Lodi to cover
Stockton. One incident did occur within the last couple of months, which was
attributed to a dispatcher, when four units were taken out and there was a delay in the
movement of units from North Stockton to cover Lodi. Mr. Meyer stated that there are
three ambulances in Lodi and one in Woodbridge during the day. At night the
Woodbridge unit is brought back into Lodi. Scheduled, non -emergency, Basic Life
Support (BLS) transportation is done by a BLS unit stationed in the Lodi community.
Mr. Meyer believed that the only way Lodi could get into the ambulance transportation
business and be the sole provider is through a competitive bid process governed by
the State and conducted by the County.
In response to Mayor Pro Tempore Hitchcock, Mr. Meyer stated that at no time has
AMR reduced units for "the bottom line" AMR uses a status systems management
deployment system that matches utilization/need to the demand in the community and
when the demand changes, so do the number of units.
Fred Hopkins, Director of Operations for Hughson Paramedic Ambulance, reported
that his company had submitted a proposal to the City of Stockton. He stated that the
reason there is a resurgence of ALS first responder programs on the fire level is
because it is the safety net of the system. He explained that if critical patients need to
be transported from the local hospital, ambulances must be used, and the fire
department stays behind as a safety net. He emphasized the importance of looking
at the fire department as a safety net and not as the total EMS delivery system. He
stated that ambulance companies in Stockton are not trying to compete with the fire
4
Continued July 2, 2002
department or race to see who gets to a scene first for statistical purposes. The
Stockton fire department is implementing its ambulances in a coordinated fashion and
in areas where private ambulance companies are not stationed. Stockton has a
public/private partnership called a public utility model. Money is collected through a
third party administrator and is shared based upon contracts and negotiated fees.
Excess revenue goes to the City to pay for its ALS first responder program. He
reported that the City of Modesto recently completed a study in which it was estimated
to cost $32,000 per year to upgrade an ALS engine company, which is far less
expensive than adding ambulances to the street.
Andy Shapiro, Director of EMS Training and Communications for the Stockton Fire
Department, stated that the City of Stockton chose to provide the fire department with
ambulances based on a number of times when there were slow responses and
complaints from dispatchers that there were no transport services available at times.
Scott Thomas introduced himself as a driver for the Lodi Fire Department and
encouraged Council to ask questions of him regarding his experiences.
Council Member Nakanishi reported that there are 7 million uninsured Californians.
Emergency rooms countywide are inundated and there is an inordinate amount of
uncompensated care. Ambulances are now used like taxicabs. He voiced support
for paramedics at engine companies, but was unsure about having ambulances
owned by the City.
Mr. Thomas reported that approximately 90% of emergency calls result in patients
going to the hospital. There has been a steady increase in call volume for many
years. He recalled that the paramedic issue was first brought up by Chief Howard. At
that time AMR did the same things that they are doing now, i.e. flooding the City with
extra ambulances and beating the Fire Department to calls. He alleged that AMR is
.playing games" about going on scene when they are three blocks away.
Pat Patrick stated that the Chamber of Commerce Government Relations Committee
was given a presentation earlier this year by Chief Pretz, and Mr. Flynn came to a
subsequent meeting. Mr. Patrick stated that AMR has been serving the community
admirably since the 1970s. He stated that the Chamber is supportive of the Fire
Department having paramedics on staff; however, it does not understand why they
would want to get into the ambulance business when Lodi already has a good
provider. It would mean only a decrease in a few seconds of response time and
would negatively impact jobs, increase government, and eliminate a good private
ambulance provider. Health care and insurance businesses are in a volatile state. In
reference to Mayor Pro Tempore Hitchcock's earlier statements about a private
company's "bottom line" considerations, Mr. Patrick pointed out that the City also has
a "bottom line" to watch because it is using taxpayer dollars. He noted that there was
an outcry from the community for the large projects which Council recently approved;
however, in the case of the Fire Department providing ambulance transport services
the desire appears to originate only from the Council.
Mayor Pro Tempore Hitchcock explained that it is not only a level of service issue, it is
a business decision and she would have a difficult time approving the proposal
without having revenue to offset the cost. The ambulance transport service would
provide offsetting revenue.
Mr. Patrick countered that a business plan has not yet been presented that assures
an offsetting revenue stream from ambulance service.
Council Member Nakanishi commented that he has been in health care for 20 years
and it has become increasingly difficult to make a profit. He pointed out that the City
is now being asked to increase salaries of the police force. He cautioned that this
proposal is a long-range plan that will affect Lodi and the local hospital dramatically,
Continued July 2, 2002
financially, and otherwise. For this reason he recommended that Council Members
who are elected at the upcoming election, be allowed to consider the issue.
Captain Ron Penix reported that he has been on scene at emergency medical calls
when there have been no ambulances in the City of Lodi. On one call, with a patient
in respiratory distress, he waited for 13 minutes before an ambulance arrived from
north Stockton. He urged Council to allow the Fire Department to provide ALS
services. He did not believe that adding more ambulances to the system would
increase the number of transports to the hospital; it would, however, decrease the
amount of time patients have to wait for life saving care.
• Julie Ballard stated that she has been an AMR paramedic for 13 years. She
advocated Lodi firefighters being upgraded to paramedics. She cautioned Council
that if it has paramedics on ambulances that are City deployed, those ambulances will
be subjected to the "round robin" system and will have to transport out of town. She
commented that some problems are related to dispatch error and there are many
hidden issues surrounding this matter.
Mayor Pennino spoke in support of the paramedic program and stated that it should be
done in the 2003-05 budget. He was opposed to hiring a consultant for $50,000. He
suggested phasing in paramedics and bringing in ambulances over the next three to five
years if certain standards are not met. Addressing the City Manager, he stated that the
City should pursue discussions with the County on how standards can be raised in Lodi.
He asked the City Attorney to look at legal issues related to this matter.
Mayor Pro Tempore Hitchcock voiced support for the Chiefs recommendation to move
forward with both paramedics and ambulance transport, and emphasized the need to be
fiscally responsible.
Council Member Nakanishi agreed that a consultant was not needed. He reiterated his
support for paramedics and voiced opposition to transport services at this time. He again
suggested that representatives from Lodi Memorial Hospital be brought into discussions
on this matter.
Council Member Land stated that he met with Fire Battalion Chief Jeff Larson yesterday
who wrote a position paper citing pros and cons of the issue. He expressed opposition to
hiring a consultant and favored option 1 as presented by the Fire Department. He noted
that there is some money in the budget that could be used for this purpose, as well as
impact fees. He stated that he would like to see a business plan from the Fire
Department.
Mayor Pennino believed that Council Member Howard would also be in support of
option 1 and suggested that direction be given to staff to develop a business plan and
report back to Council.
Mayor Pro Tempore Hitchcock expressed concern that Council is making decisions at an
informational Shirtsleeve Session and believed that such direction should be given at a
regular meeting.
Mayor Pennino suggested that the matter be placed on the agenda for the first regularly
scheduled City Council meeting in September.
D. COMMENTS BY THE PUBLIC ON NON -AGENDA ITEMS
None.
Continued July 2, 2002
E. ADJOURNMENT
No action was taken by the City Council. The meeting was adjourned at 8:58 a.m.
ATTEST:
Susan J. Blackston
City Clerk
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Mayor's & Council Member's Weekly Calendar
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WEEK OF JULY 2, 2002
Tuesday, July 2, 2002
7:00 a.m. Shirtsleeve Session
1. Paramedic Program Update
11:00 - 2:00 p.m. Pennino. City's New Safety Awards Program Kickoff Luncheon
(to be held in the parking lot behind City Hall)
Wednesday, July 3, 2002
8:00 a.m. Pennino. San Joaquin Regional Rail Commission meeting.
6:00 p.m. Pennino and Hitchcock. Celebrate America - located on the
West Lawn at Hutchins Street Square
8:00 P.M. City Council Meeting (adjourned from 7.00 p.m.)
Thursday, July 4, 2002 Independence Day
Holiday City Government offices will be closed allday -N
Oooh Ahhh Festival at Lodi Lake Park
Friday, July 5, 2002
Saturday, July 6, 2002
Sunday, July 7, 2002
Monday, July 8, 2002
Disclaimer: This calendar contains only information that was provided to the City Clerk's office
counciAmis6mcalndr.doc
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9<IFOR�
L 1 1
Michael Pretz
FIRE DEPARTMENT
Steven Raddigan
Fire Chief
Information Technology
Verne Person
217 WEST ELM STREET
Kevin Donnelly
Fire Marshal
LODI, CALIFORNIA 95240
Training Officer
Ron Heberle
ADMINISTRATION: (209) 333-6735
George Juelch
Battalion Chief
Battalion Chief
FIRE PREVENTION: (209) 333-6739
Jeff Larson
Battalion Chief
FAX: (209) 333-6844
July 2, 2002
TO: Mayor, Members of Council,
Dixon Flynn
FM: Michael Pretz
RE: Paramedic Program Update
Executive Summary
Council has expressed the desire to fully explore several options for providing paramedic
services to the community. In order to facilitate this need, fire department staff has met with
several private provider representatives to develop options for council consideration. These
options are based upon a requirement by local government to provide public safety services to
the community.
The City of Lodi supports private enterprise; one important hallmark of private enterprise
is a competitive market system. We believe the medical transport market is under -served and the
citizens of the City would receive better services with additional providers. To that end, the City
has encouraged additional providers to become a part of the system. For the past 7 years the city
has experienced an alarming trend in Emergency Medical Services (EMS). We believe this trend
will only get worse.
Since 1995, the City of Lodi has experienced an 11.9% increase in population, a 35%
increase ambulance response time, a 72% increase in emergency transport volume, and a
reduction in the number of ambulances within the city limits.
The fire department has developed four options to increase the level of service provided
to the community. These options include:
1. The Lodi Fire Department provides transport services
2. The Fire Department enters into a partnership with AMR
3. The Fire Department enters into a partnership with Hughson Ambulance
4. The Fire Department enters into a Third Service Partnership
Problem Background:
Since 1995, the City of Lodi the number of ambulances available to the citizens of the
community has been inconsistent. This inconsistency has led to increased risk to the community
and makes the provision of emergency medical services difficult for fire department first
responders.
Providing for public safety is the responsibility of the City Council. One aspect of public
safety is emergency medical care. The Fire Department has been delegated the task of providing
this service to the community. The provision of advanced life support throughout the City of
Lodi has been inconsistent. The inconsistency is exacerbated by an aging growing population
and by an increasing population. Moreover, there are several events, outside of City control, that
will have an impact on the provision of this service. These events include, changes in the
Medicare/ MediCal reimbursement structure, increasing number of hospital Emergency Room
closures, leading to increased out of service time for ambulances, and profitability issues with
private providers.
The problem the City of Lodi faces in providing emergency medical care for the
community can best be described in examining the following data.
The population of Lodi has been steadily increasing. In 1995, the population was
approximately 53, 100. In 2002, the estimated population has increased to approximately
59,400, an increase of 11.9%.
In 1995, there were 3 ambulances stationed in Lodi (Lodi News Sentinel), by October
2000, there were only 2 ambulances stationed in Lodi (Council minutes). Moreover, AMR (Rick
Keiser, Operations Manager) stated in the October 2000 Council shirtsleeve session, they (AMR)
frequently pulled the 911 ambulances out of Lodi to do inter -facility (hospital to hospital)
transfers. This practice is ongoing, however, with the addition of a BLS unit, the frequency of
the 911 (ALS) ambulances performing inter -facility transfers has been reduced.
When the fire department announced their paramedic proposal included transport, AMR
increased coverage with a third ambulance stationed north of Lodi in Woodbridge. During the
past 5 years, additional ambulances have been stationed in Lodi as a direct result of Council
inquiries and fire department attempts to increase services levels to the community. After the
inquiries are answered and the concern wanes, the number of ambulances in Lodi are reduced.
Since 1996, the average response time for AMR has increased from 3.94 minutes (1996)
to 5.31 minutes (2001), an increase in response time of 35%. (County EMS data) Response
time does not include calls outside the City of Lodi.
Transport volume has increased from 1620 calls (1996) to 2781 transports in 2001 an
increase of 72%. (County EMS data) Call volume does not include calls outside the City of
Lodi.
Since April 2000, The Stockton Regional Emergency Dispatch Center has tracked the
number of times; Lodi and Stockton experience low ambulance coverage. Low ambulance is
defined as less that 2 ambulances in Lodi and less than 3 ambulances in Stockton. In a recent 6 -
week period, February 2002- March 18, 2002, there were 20 incidents of 1 ambulance or less in
Lodi. On May 30, 2002, Lodi Fire was informed that there were no ambulances in the City and
that ambulances would be coming out of Stockton. This issue remains the primary reason the
City of Stockton Council voted to allow the Fire Department to begin ambulance transport.
In 1995, the City of Lodi adopted the San Joaquin County EMS ordinance, the ordinance
provides a permit process for private and public ambulance providers, response time criteria, and
the stationing of at least one ambulance in the City of Lodi. The stationing of this ambulance has
been defined as north if Armstrong Road. The urban response time criteria is; 8 minutes, 90% of
the time.
Staff Recommendation:
In order to develop proposals that would increase the level of service to the community
and offset costs to the greatest extent, the Fire Department has been exploring several
opportunities to partner with private providers. The Fire Department recommends Option #1
because it has the greatest potential to recover the cost of providing this service. However,
politically, a partnership that allows the greatest cost recovery should be considered.
The following options are presented for your review, discussion, and direction.
Moreover, staff further recommends Council direct staff to develop a Request for Proposal (RFP)
for a third party consulting fine to review staff work and make a recommendation for Council
approval.
Option#1 Lodi Fire Department Paramedic Program.
This option is the same one proposed earlier. The fire department would hire 15
additional personnel to staff existing engine and truck companies. These individuals will already
be paramedics. The city would purchase three ambulances and begin transport services. I have
run several transport scenarios with the fire department assuming 30%, 50%, 70%, and 100% of
the call volume. As the department approaches 100% of the emergency transports the City
recovers its costs and produces a revenue stream. Several financial models have been produced
and will be included in the future presentation.
Option #2 Partnership between the Fire Department and AMR
I have held 2 meetings with AMR representatives to discuss possible partnership
proposals. In each meeting AMR has reiterated their desire to form a partnership. AMR has
offered to pay the differential between firefighter and paramedic. Using a 15% pay differential
and 15 paramedics, the cost to AMR is approximately $113,640 per year at the build -out of the
program. AMR has offered to train firefighters to the paramedic level utilizing their paramedic
school. In addition, AMR will allow the City to purchase medical supplies through their
acquisition process.
The fire department has asked to explore utilizing a single ambulance as a supplemental
response vehicle. This concept is in use in the City of Santa Clara and San Jose. This unit would
be used when AMR units are experiencing long responses or when the severity of the injuries at
an incident dictate rapid transport to the hospital. The experience from Santa Clara indicates
about 50-60 responses per year. AMR will bill the patient but the City would keep the revenues.
Enclosed in your packet is a copy of the response from AMR.
Option #3 Partnership between the Fire Department and Hughson Ambulance (HPA)
The Hughson Ambulance company (HPA) currently operates in Stockton with 3-4
ambulances. HPA has taken over districts abandoned by AMR in the Stockton inter -city. HPA
board members have expressed a desire to partner with the Lodi Fire Department to provide
transport services to the City. The Fire Department would hire additional paramedics for the
engine companies. The preliminary HPA proposal will provide the city with 1 reserve
ambulance stationed at a fire station. HPA would also pay a differential between firefighter and
paramedic estimated at $38,000 per ALS engine. In addition, HPA has expressed and interest in
revenue sharing with the City. Hughson ambulances would be under the direct control of the fire
department. One member of the board for HPA is the medical director for the corporation and
would be willing to function in that capacity for the fire department. Enclosed in your packet is
a copy of the Hughson Ambulance Proposal.
Option #4 Advanced Life Support (ALS) Third Service
The fire department would provide paramedics on engine companies and a non-profit
provider would provide ambulances staffed with EMT's and paramedics.
The non-profit provider would also provide an additional service of returning the patient to their
home as necessary. Revenue from the system would be used to cover costs and enhance the
system as needed.
Summary
In researching the fire department proposal, I have utilized the information provided by
the Reason Public Policy Institute, a leading proponent of privatization. In one policy paper, the
author addresses "high performance" emergency medical systems, citing 5 cities. Four of the
cities utilize fire department paramedics as first responders and a private provider as the transport
agency. In all cases, this means the fire department does the lions -share of the work, i.e. provide
the initial care and the private provider collects the revenue. In each of the options presented, the
Lodi Fire Department will provide an increased level of service to the community through
paramedic services. The cost of providing increased service will be partially offset by revenue
from private providers.
The Reason Public Policy Institute also notes that in the top 200 cities with a population
of 100,000 or more, 50% use a fire -based or third service system, 22% use a combination of fire -
based, private system and only 28% use a private only system.
On May 28, 2002, the City of Stockton Council gave its approval to allow the Fire
Department to enter into emergency transportation. The fire department proposal will place 5
ambulances in service in the core area of Stockton. The Stockton Fire Department will have to
apply for a permit to provide this service. According to the State of California Emergency
Medical Services Agency, as long as the provider can meet the County requirements, they must
be awarded a permit.
There has been a persistent rumor that San Joaquin County Board of Supervisors will ask
for an RFP to award exclusive jurisdiction rights to a single company. This rumor has surfaced
whenever there are ambulance issues. While it is within the rights of the Board to award this,
there is some belief that this action will open the door to renewed animosity between all the
private providers. Should AMR not win the contract with the County for exclusive rights to
transport, they will be forced to leave the County and service provision will resort to the
successful bidder.
Because this is a contentious issue, fire department staff recommends a third party
consultant be hired to review the Fire Department proposal, as well as the public/private
proposals and recommend a course of action to Council. A Request For Proposal (RFP) wold
cost between $40,000450,000 and could be completed within 4-6 months.
June 10, 2002
Name and Address
As you are aware, the Lodi City Council has expressed the desire for the Fire Department
to explore and identify options for providing paramedic services to the citizens of our
community. The fire department is desirous to provide paramedic and transportation
related services to the City and surrounding area. In so much as this is the desire of the
fire department; we acknowledge there currently exists public/private partnerships
between fire departments and ambulance companies that have proven successful in this
endeavor. Therefore, we are looking for proposals from private ambulance providers in
which we feel we could successfully partner with. The goal of such partnership is to
maximize pre -hospital medical services to the citizens of Lodi; and secondarily a
partnership that allows the greatest recovery cost to ensure the financial needs of each
partner is fulfilled.
In receiving this request for a proposal, you have been identified as a private ambulance
provider who may be interested in partnering with the Lodi Fire Department to provide
such services. The need to provide additional pre -hospital services to the City of Lodi is
described as follows:
The population of San Joaquin County as well as the City of Lodi has seen a modest
increase. In 1995, the population of Lodi was approximately 54, 400. In 2001, the
population increased to approximately 57,800, an increase of 6.25%. During the next
several years, the population in the Central San Joaquin Valley will grow significantly
and the area is described as one of the fastest growing region in the state.
Pending Council approval, the Lodi Fire Department plans to move forward to place
paramedics on its engine companies, hiring a total of 15 paramedics. The fire department
will be responding on all advance life support (ALS) calls for service and will provide
such services upon arrival. A partnership with a private ambulance provider will be for
the "transportation" of a person(s) in need of such services. The revenue or cost recovery
of such services then would be shared between both partners, of which the share doesn't
necessarily have to be 50/50.
The following areas of concern are considered critical to the fire department in creating a
partnership and should be addressed in detail when submitting a proposal for further
consideration. It should be noted that this is not a formal Request for Proposals (RFP),
all submittals are confidential and not subject to public disclosure, and all submittals
remain the property of the Lodi Fire Department for use in determining whom the fire
department will affiliate themselves with should a public/private partnership be created.
➢ Medical Services Director /EMS Coordinator. In providing ALS services, a
Medical Services Director (Doctor) is required to oversee the overall operation and
ensure training requirements of the provider(s) is being met or exceeded. An EMS
Coordinator is an in-house position that would coordinate staffing levels, scheduling,
training Q-A/Q-I, planning (normal and special events), cost recovery, and other
duties as agreed upon.
The ability of a private ambulance company to be able to provide one or both
positions is not a requirement, however the need exists and a cost for said services
will have to be identified. The proposal should indicate if either position or both
could be filled by the provider and at what cost.
➢ Response Time Criteria. In providing ALS services, response times are critical. The
fire department as well as the ambulance company will have to comply with the ALS
response standards developed by County EMS when performing said services. In as
much as the Lodi Fire Department will be responding to all calls for ALS services,
the actual arrival time of the transporting ambulance is not as critical.
The proposal should address what you believe will be the appropriate response
time(s) within the City on handling transportation duties only; and outlining
escalating penalties on a minute by minute basis for late arrivals.
➢ Paramedic Premium. In as much as the City of Lodi will be providing the
paramedics, the city's cost for these services will surely exceed those of the
ambulance company. In order to equalize the cost of paramedic services, the
ambulance company will be required to pay to the City a premium per paramedic
over and above the revenue sharing program.
This cost will have to be determined at such time when a partnership is formed. It
should be noted, the difference between the City of Lodi firefighter rate and
paramedic rate would result in an annual premium of approximately $7576 per
paramedic being paid to the City.
➢ Revenue Sharing Program. The City of Lodi has no experience in billing for
medical transportation related services. We are of the understanding that most if not
all -private companies handle all billing for service where most if not all -public
entities contract out the billing services. The actual number of transports in the City
of Lodi and the surrounding area can be obtain through the County EMS department.
Based on the City's expected costs, approximately $1.15 million dollars and the
partners expected costs; a best -case scenario revenue program needs to be created.
In an effort to ensure complete neutrality, the City would like to visit utilizing a third
party independent of both for handling the billing of service. The proposal needs to
address recommended billing companies for consideration.
➢ Ambulance Provided to the City. The selected partner needs to provide an
ambulance for use by the fire department, which will be maintained and staffed by
fire personnel. The fire department would expect to use the unit for transport of ALS
patients when there are no transport ambulances available in the City or within Zone
4. Additionally, the unit could be utilized for transfers in non -emergency situations
such as transports from the local hospital to home (City / Zone 4 area only), transports
between local healthcare facilities, and transports between ground and air -medical
providers as requested.
The proposal needs to address your recommended uses and/or limitations of the use
of this unit by the fire department. The final terms of use of this dedicated unit would
be negotiated between the parties.
➢ Plans for Expansion. As stated above, the City of Lodi and the surrounding area has
grown and will continue to grow in the not so distant future. The proposal needs to
address how the ground pre -hospital medical services program will grow as the
population grows. Which of the following factors if not all would you address when
planning for expanding the level of service:
Percentage of population growth within a certain time period, ALS call volume as
well as other calls for transportation related services, response times, and any other
conditions not listed. Likewise, the plan should also address those factors, which
would be considered for the downsizing of pre -hospital medical services.
Length of Contract. The City understands the private provider may incur "real'
startup cost to create a partnership with the Lodi Fire Department. In order for the
private provider to re -coop those costs, the costs need to be amortized over a certain
period of time, which will in essence turn out to be the "original' term of the contract.
The proposed length of contract should also include renewal time periods, annual
performance/compliance reviews, methods of reconciliation for
performance/compliance reviews found to be deficient, and a provision where the
City would have the first right of refusal to purchase the equipment (fair market
value) of the provider should that provider determine they can no longer operate
under the terms of the contract, failure to meet the requirements of the contract, or at
the expiration of the contract.
It needs to be clearly stated that by just submitting a response proposal is in no way to be
considered a contract between the submitting company and the City of Lodi. The content
of each proposal will be reviewed in detail with a recommendation submitted to the City
Manager and City Council indicating who the fire department feels is best suited to
affiliate ourselves with. It is expected that any contact creating a public/private
partnership for pre -hospital medical services will be negotiated in good faith, extremely
detailed as to who is providing what services and when, and lastly, legally binding. This
process could take up to twelve months to complete.
If you choose to respond, all such responses need to be sent to the office of the Fire
Chief, Michael Pretz, 217 West Elm Street, Lodi, California 95240 no latter than Friday,
June28, 2002, 4:30 PM. If you need additional information prior to responding, you can
call Chief Pretz at 209-333-6735.
AMERICAN MEDICAL RESPONSE
June 20, 2002
Mr. Michael Pretz
Fire Chief
City of Lodi
Fire Department
217 West Elm Street
Lodi, CA 95240
Re: Public/Private Partnership
Dear Chief Pretz:
I am writing in response to your letter dated June 10, 2002, regarding the City's desire to
establish a public/private partnership with an ambulance provider as an option for providing and
funding paramedic services to your citizens. As you are aware from our prior discussions on this
issue, AMR has a great deal of experience in structuring and implementing these types of
programs and has expressed a willingness to discuss a public/private partnership with the City of
Lodi. In view of the contents of your letter which states "that this is not a formal request for
proposal (RFP)", one could assume that the contents of your letter did not have City Legal
Counsel review, and therefore we thought it may be helpful to address three important legal
principles which must be taken into account in structuring this type of program.
GOVERNING LEGAL PRINICPLES
The California EMS Act. First, under the California EMS Act (Health and Safety Code
Section 1797, et seq.), counties and their designated local EMS agencies are the public entities
with legal authority over the county -.vide EMS system, including the delivery of both transport
023.217727.1
7575 Southfront Road, Livermore, CA 94550
Phone (925) 454-6000 • Fax (925) 454-6009
and non -transport services within cities. A limited exception to this rule exists for cities that
have rights under Section 1797.201 of the EMS Act, but that exception does not apply to the City
of Lodi. A county's regulatory authority includes designating ALS providers; establishing
exclusive operating areas, when appropriate; establishing and enforcing dispatch, patient
destination and patient treatment protocols; establishing and enforcing response time
requirements; and evaluating the clinical performance of the providers in the system. Although
your letter specifically discusses only the authority of the San Joaquin County EMS Agency to
establish response time standards, we assume the City also recognizes the County's authority
over these other functions. We also assume that you are aware that the City knows that it does
not itself have any regulatory authority over emergency ambulance services.
Medicare and Medi -Cal Reguirements. The second important legal principle to be taken
into account is that ambulance transportation is the service which is paid for and regulated by
Medicare, Medi -Cal and other public health care programs. For this reason, an ambulance
provider must enroll with and be certified by Medicare and Medi -Cal to bill these programs.
Fortunately, the rules of these programs (and Medicare rules in particular) recognize the
synergies between non -transporting first responder agencies and ambulance providers by
permitting the transport provider to bill for services rendered by first responders when an
appropriately structured subcontract exists with the first responder agency. However, the rules
of these programs require that the ambulance provider, as the certified/regulated entity which
submits claims and receives payment from the government, maintain a degree of legal authority
over all the services it bills for, including those provided by first responders. This means the
only legally appropriate way to structure this kind of an arrangement is for the ambulance
2
023.217727.1
provider to enter into a subcontract with the first responder agency wherein that agency will
provide services in support of the transport component. It is not legally appropriate for the first
responder agency to be the primary entity which delivers medical transportation through a
subcontract with a transport provider.
The Anti -Kickback Statute. A third significant legal requirement, the Medicare Anti -
Kickback Statute, limits the amount of compensation which can be provided by an ambulance
company to a city or other public agency which dispatches, or contracts with another entity to
dispatch ambulances in response to 911 calls. The Anti -Kickback Statute makes it unlawful to
pay for the referral of patients. The Office of Inspector General of the Department of Health and
Human Services (OIG) views the performance of the 911 dispatching function as the "referral"
of patients. Therefore, the Anti -kickback Statute prohibits ambulance providers from paying
more than fair market value to cities or other agencies which perform the 911 dispatching
function. The OIG has indicated that when an ambulance company pays a public 911
dispatching entity more than fair market value for services performed by the dispatching entity —
including first responder services —this may be viewed as a disguised kickback. In fact, this
concern was raised very recently by the OIG in its Draft Compliance Program Guidance for
Ambulance Suppliers, which was published in the Federal Register on May 9t'. Therefore, any
payment made by an ambulance company to the City for these services would need to be limited
to fair market value.
3
023.217727.1
With the foregoing principles as background, AMR remains very interested in entering
into a public/private partnership with the City of Lodi, which will stand the legal test as
described above.
We are aware that our response is necessarily lacking in certain specifics. However it is
our opinion that in agreeing to certain provisions of your "Informal RFP" we would expose both
our agencies to sanctions from federal regulators. We have found in structuring these
arrangements elsewhere, there are a number of operational and financial issues that must have
both City as well as County Legal Counsel review. We hope the foregoing will lead to further
discussions with the City, in collaboration with the San Joaquin County EMS Agency on how to
best structure an effective ALS first responder program in Lodi.
Very truly yours,
Louis K. Meye
CEO, Northern Pacific Region
CC: Dixon Flynn, Lodi City Manager
Elaine Hatch, EMS Director — San Joaquin County
Michael Scarano, Esq
James Ridenour, Vice President
4
023.217727.1
H UG HSON
PARAMEDIC
AMBULANCE
COMPANY,
INC.
Hughson Paramedic Ambulance Service
A Proposal to the City of Lodi
For the Provision of
Emergency Ambulance and
Transportation Services
June 20, 2002
A Proposal to the City of Lodi June 21, 2002
June 20, 2002
Michael Pretz, Fire Chief
City of Lodi
217 West Elm Street
Lodi, CA 95240
Dear Chief Pretz:
Hughson Paramedic Ambulance Service Inc. is pleased to present for your
consideration the enclosed proposal for the provision of Emergency
Ambulance and transportation Service. We believe our proposal
addresses the spirit of your RFP as well as the required content.
Our proposal creates a true Public/Private Partnership. It brings together
the experience and commitment of Hughson Paramedic Ambulance
Service with the desire and knowledge of the City of lodi. Our combined
resources create a strong entity that is limited solely by our imaginations.
We hope you find our proposal acceptable and complete. Should you
have any questions, please don't hesitate to contact me.
Sincerely,
Thomas E. Crowder, MBA
President/CEO
A Proposal to the City of Lodi lune 21, 2002
Executive Summary
Hughson Paramedic Ambulance Service has positioned itself as a leader
in the EMS and medical transportation fields. Our success is due to a
strong commitment to quality care and the belief that service comes
before profits. HPA has experienced consistent growth since its inception
in 1989. Our growth comes as the result of establishing and maintaining
long-term relationships with public safety agencies and healthcare
institutions.
Our proposal to the City of Lodi is unique in that we seek to establish a
"Start Up" operation together with the City and grow that product into a
successful entity. Our proposal has several key elements that drive this
project.
O Establishment of an EMS Fund
D Funding of ALS engine companies
O Revenue Management Process
O Growth and expansion plans
O Cooperative Environment
O Proven Record of Success
HPA offers the City a fresh alternative. We seek to explore opportunities
With the City of Lodi. We see the City of Lodi as an opportunity to
demonstrate that Public and Private ventures can and will success.
A Proposal to the City of Lodi June 21, 2002
Company Profile
Hughson Paramedic Ambulance Service, Inc. was founded in 1989 by
Thomas Crowder. Mr. Crowder saw a need for emergency ambulance
service in the community of Hughson and without any public financial aid
implemented service in a small rural community.
The Company was one of the first to establish distinct operating units that
specialized in EMS and non -emergency transportation. The EMS section
provides dedicated 911 services while the non -emergency division
provides high quality cost effective scheduled services. Support divisions
such as purchasing, human resources, fleet maintenance, risk/safety and
training are consolidated to be cost effective and reduce indirect
operating costs.
As a healthcare provider, the Company is proud to state that its owners,
Thomas Crowder and Dr. John J. Casey are both practicing clinicians. Mr.
Crowder has been a paramedic for over 17 years and is highly respected
in the EMS community. His devotion to his field is evident by the fact that
he works regularly on a paramedic unit in order to personally judge the
care being provided by his staff.
Dr. John J. Casey is an Orthopedic Surgeon in Stanislaus County providing
emergency care at several local hospitals. He has served on several
boards and commissions and is currently on the Stanislaus County Trauma
Steering Committee. Because of his extensive time spent in the
emergency room, Dr. Casey is in close contact with pre -hospital personnel
and contributes to their skills and knowledge through direct interaction.
A Proposal to the City of Lodi June 21, 2002
The Company's Deputy Director of Finance is Ms. Erica Lacy -.-..Ms. Lacy has
been with Hughson Ambulance for over ten years and has been
instrumental in guiding HPA in its growth. Ms. Lacy has an extensive
background in corporate financial management, accounts receivable
processing, capital expenditure funding and budgeting. She directly
manages all of HPA's service contracts, ancillary divisions and long-term
planning process.
The Deputy Director of Operations is Mr. Fred Hawkins. Mr. Hawkins has
been managing ambulance services and EMS systems since 1976. He has
managed, directed, supervised or consulted on EMS projects throughout
the country. Mr. Hawkins has created partnerships and joint ventures with
fire departments, hospitals and allied provider agencies. He is a Master
Instructor in System Status Management and EMS Deployment Strategies
and has lectured on the subject in California, Oregon, Washington,
Colorado and Indiana. Mr. Hawkins continues to consult on EMS projects
for a variety of firms. In 2001 Mr. Hawkins was instrumental in designing an
accreditation process widely utilized by healthcare payers.
Mr. Barry Hickerson is the Company's Clinical Services Director. Mr.
Hickerson is a Flight Paramedic and oversees HPA's training and
education process. Mr. Hickerson established quarterly skills testing for
HPA paramedics and EMTs. This one on one process focuses on key skill
proficiencies and facilitates remedial learning opportunities. Mr. Hickerson
has been involved in a number of pre -hospital research projects and is an
instructor at the Doctors Medical Center Paramedic Training Program.
A Proposal to the City of Lodi June 21, 2002
Today; HPA operates a fleet of seven paramedic -equipped ambulances
and nine basic life support ambulances. The growth of the company has
permitted HPA to update its fleet with additional units due to arrive soon.
Our operations plan separates our services into distinct units. The
ALS/paramedic units are assigned to the 911 /EMS system. They do not run
transfers or non -emergency transports. This program has been extremely
successful for HPA and has facilitated our growth in San Joaquin County.
Our basic life support division responds to all non -emergency and .
scheduled transports. Resources are matched to demand and reserve
units activated when necessary.
A Proposal to the City of Lodi June 21, 2002
Medical Services Director / EMS Coordinator
Off-line medical control is a vital part of a quality pre -hospital care
program. The Physician's role is not only one of accountability but of
leadership and direction. As part of our proposed alliance we will expand
the role of our Medical Director to include the personnel of the Lodi Fire
Department.
The Medical Director will participate in the patient care audit process and
provide remedial education when necessary. The Medical Director
provides all participating personnel with a source of clinical and
professional feedback.
In addition to the Physician Medical Director, HPA will assign a full-time
EMS Coordinator/Project Manager to Lodi. The EMS Manager will be
assigned to a peak load ALS unit that will operate from 0700-1800
weekdays. HPA and the Lodi Fire Department will jointly select the EMS
Manager. The EMS Manager will coordinate all on-site activities including
training, re -stock, customer feedback and project support.
The EMS Manager will be a clinical role model and be capable of
addressing clinical and operational issues.
HPA employs six (6) EMSA approved accreditation officers who can
provide field training to paramedic students and candidates. Our
preceptors are available to the City of Lodi to assist in the field training of
ALS engine personnel.
A Proposal to the City of Lodi June 21, 2002
Response Time Criteria
in anticipating response time standards it is difficult without first knowing
the parameter to be served and the volume of calls. Since that type of
analysis can only be made with validated data retrospectively, we
propose establishing incremental standards that will drive response times
such as out of chute or enroute times.
The current standard of enroute within 60 seconds or less to all emergency
responses prompts the units to readiness. Thereafter, the only variable is
speed and distance. To address the speed and distance issue, HPA will
conduct regular mapping courses for personnel assigned to the Lodi
project. Upon commencement of the program, HPA and the City will
analyze the response times monthly until we reach an optimal level of
performance.
A Proposal to the City of Lodi June 21, 2002
Paramedic Premium
Based upon the information provided by the City we estimate the annual
cost differential to be approximately $38,000 per ALS engine company.
This figure closely resembles other fire based ALS engine company costs.
The City's allocation of the retained earnings in the Lodi EMS fund
proposed in the revenue sharing program section would fund the ALS
engine program. As ALS ambulances and engine companies are
added, the revenue stream from additional transports shall be utilized to
cover the cost of the ALS implementation costs.
A Proposal to the City of Lodi June 21, 2002
Revenue Sharing Program
In the Lodi response area there is a limited number of ambulance
transports that can be captured initially. That volume is divided by the
number of licensed ambulances in service at any given time. The
addition of ambulances into Lodi will not increase the aggregate volume
but merely change the equation of calls per unit. Our proposal is to
create an EMS fund that captures all revenue generated by contracted
transports and ancillary healthcare services. The revenue is then
allocated to several entities in accordance with the business plan being
proposed. The initial entities would be the City of Lodi and Hughson
Paramedic Ambulance Service. The City may use its retained funds for
upgrading its engine companies to ALS, EMD training for dispatchers, or
any purpose the City wishes. Hughson Ambulance would use its share of
the EMS fund to cover its operational costs associated with its Lodi
operations.
A third party billing service will be jointly selected by the City of Lodi and
Hughson Paramedic Ambulance Service. That third entity will process, bill
and collect all revenues generated from transports in the Lodi area.
Revenues will be deposited by the third party service, and the fund
balance, less billing expense will be transferred to an operating account
at the close of each calendar month.
Monthly, Hughson Ambulance shall submit an invoice for direct operating
costs associated with the Lodi agreement plus an administrative fee. The
direct operating budget is developed jointly and monitored monthly. That
invoice shall be paid from revenues deposited into the fund. Hughson
Ambulance will fund the account initially or "Loan" the fund start up costs.
A Proposal to the City of Lodi June 21. 2002
All records, transactions, charges to or claims paid are conducted jointly
by the City of Lodi and Hughson Ambulance with dual signatures.
Our proposal creates a true cooperative venture. Any assistance
provided by the City to HPA that reduces direct expenses such as housing,
dispatch, fuel or maintenance enhances the fund balance. The balance
and/or projected revenues can be utilized to expand programs.
A Proposal to the City of Lodi June 21, 2002
Ambulance provided to the City
We will provide one (1) reserve ambulance to be stationed in the City of
Lodi and utilized as stated in the RFP document. The ambulance will be
stocked, maintained and supplied by Hughson Paramedic Ambulance.
The City of Lodi shall provide a secure location for the ambulance. All
revenues generated from transports shall be integrated into the Lodi EMS
Fund.
The fire personnel staffed ambulance is a useful tool during periods of
unusual system overload. Since the ambulance would likely generate
revenue without additional expense that revenue less the billing cost
would ultimately become retained earnings for the City.
A Proposal to the City of Lodi June 21, 2002
Plans for Expansion
The City of Lodi has expressed an interest in creating a true Public/Private
Partnership. We believe that in order to nurture the relationship the service
delivery model must be creative and adaptive. Our business plan
includes expansion into the non -emergency market and the scheduled
expansion of the ALS program in the City of Lodi and the unincorporated
areas with those added revenues being added to the EMS fund.
Hughson Ambulance has extensive experience in deployment strategies
and developing medical transportation programs. We believe that a
locally based and operated system that keeps 100% of the retained
earnings within the community can be marketed and produce a
competitive business entity. The non -emergency market can include
basic life support transports, wheelchair van and shuttle van services as
critical care transportation.
By analyzing data available at the EMS Agency we can anticipated and
identify growth opportunities. The EMS Fund process will provide us with
revenue indicators that will assist in creating thresholds that trigger
implementation of additional units. As a Primary PSAP, the City of Lodi
can triage the non life threatening calls out of the EMS system and create
a public safety incident in which a paramedic unit or engine company
responds first to assess the situation. if treatment or transportation is
necessary, the on -scene unit can handle the task.
We propose the creation of a "Business Health" program where ALS
engines or ambulances provide immediate first aid services to injured
workers and coordinate their care for a minimal fee.
A Proposal to the City of Lodi June 21. 2002
We propose the creation of a "Community Health Program" in
conjunction with Lodi Memorial Hospital that provides pro -active health
and safety services throughout the community. The establishment of a
subscription program that provides initial funding of services and saves
residents money should they use emergency services. Between calls,
ambulances and firefighters perform home safety inspections and provide
valuable information on other healthcare related services.
Paramedics and firefighters become the eyes and ears of the local
physicians by performing home exams when requested.
Development of a child safety program in the City of Lodi. Hughson
Ambulance owns a "Freddie the Firetruck - Andy the Ambulance" unit
that is designed to capture the attention of children 12 years and
younger. The unit would be stationed in Lodi and used to educate
children about a variety of safety issues.
A Proposal to the City of Lodi lune 21, 2002
Lenath of Contract
We are proposing an initial contract term of three (3) years with the option
to renew if acceptable to both parties. The contract terms to be
negotiated. The elements of our proposal are fluid in that should the City
of Lodi elect not to renew the agreement or termination is executed due
to breech that the EMS Fund can be assumed or transferred to a new
provider.
A Proposal to the City of Lodi June 21, 2002
■ Bureau
j M Lodi E. Markdo
et SL, Stodn, CA 95202;9438566.22
5202;9438566
■ Lodi Bureau
101 W. Locust St, Lodi, CA 95240; 967-7429
Mant
oCa ■ Mother Lode Bureau .168 N. ca Bureau
ThC Record 166 N. Maple Ave., Manteca, CA 95336; 2343954
Monday, lune 17, 2002 ■ L520 N. Main St., Argft Camp, CA 95222:736-9554
kmbul,nce firms crowd into Calavera&"_:
Francis P. Garland
t Bureau Chief
AN ANDREAS — More
3ulances will be on Calaveras
.nty roads come July 1, but
to emergency -medical offi-
s say that's not necessarily a
d thing.
he Mountain -Valley Emer-
cy Medical Services Agency
week gave American Legion
zmlance of Amador County
the Ebbetts Pass Fire Protec-
t District permission to oper-
ambulances in the San
Ireas and Arnold areas,
>ectively.
'he agency also said San
Ireas Ambulance could
and its service into Angels
np.
Inti( now, American Medical
ponse had been serving
;els Camp and Arnold, while
Andreas Ambulance had the
Andreas area to itself.
lut starting July 1, dispatch -
will rotate calls among
viders in those areas, mean -
they'll have to share busi-
ness. And that likely will hurt all
of their bottom lines, according
to Doug Petrick, American Med-
ical Response's operations direc-
tor, because there aren't many
calls to go around.
It's a small county," he said of
the county's 40,000 inhabitants.
"The profit margins will be pret-
ty slim when you're talking
about that few calls. This could
have a potentially huge impact
on the system."
Although the changes will
mean more ambulances to serve
the public at the outset, officials
worry that fewer calls will mean
less revenue for providers. And if
some experience financial diffi-
culties, they could start to cut
corners if not fold up shop
entirely.
"When they're hanging on by
their nails financially, they're
forced to cut costs in areas like
equipment or staffing," said
Steve Andriese, the Mountain -
Valley Emergency Medical Ser-
vices Agency's executive
directors And those are
absolutely essential to a good Rick Jones, the agency's a panic situation for them," he
system." response and transport coordi- said. "They hang on every calk'..:
Andriese said his agency will nator, said the agency prefers to and if they lose one, it's a majgv
monitor the situation "to make see exclusive operating areas impact." '
sure the public gets a safe ser- wherever possible, because the Pilkington, who chose.: tb,
vice." open -market approach doesn't expand into Angels Camp,,
The changes were triggered
by American Legion Ambu-
lance's request to serve the San
Andreas area. Al Lennox of
American Legion Ambulance
would not discuss his company's
plans.
Bill McFall of Valley Springs
Ambulance said American
Legion has an unfair advantage
because it has exclusive rights to
operate in Amador County and
can afford to run its ambulances
at a loss in Calaveras County.
Calaveras County has no
exclusive operating areas, which
means the Mountain -Valley
Emergency Medical Services
Agency cannot'deny an ambu-
lance company the right to do
business in a particular area as
long as it meets some basic
requirements and has a clean
history.
work well for ambulance service.
because she said her company`
"Free enterprise works great
could not survive by sharing,
for some things like the restau-
calls in San Andreas alone;'.
rant business, because the pub-
would like to see some sort'of' •
lic can vote with its feet," he
Zone -protection measures inti-,'
said. "They can choose not to go
tuted in Calaveras County .tti.,,
to a restaurant if the service isn't
guarantee that providers can:
good. You dont have that choice
stay afloat financially
when you dial 911."
Jones said Calaveras County,
In Calaveras County's case,
could establish exclusive operat- ,
dispatchers will rotate calls
ing areas but it would be up to`
among providers in the different
the Board of Supervisors to do sot
areas come 8 a -m. July 1. That
_ and it would take up to two;
could make slow going even
years for that change to take
slower, said Gail Pilkington of
effect.
San Andreas Ambulance.
The board is expected to hold'
I might go all day without
getting a call," she said. "That's
a study session on the issue
kind of devastating, because my
within a few weeks, said Clay.
Hawkins, the county's acting:
people are getting paid regard-
administrative officer.
Andriese acknowledged that
■ To reach Lode Bureau Chief Fran-,
providers in competitive areas
cis P Gedand, phone 7 4 or
have it tough. "It creates almost
e-mail garland®goldrush.com
American Medical Response
P.O. Box 7423
San Francisco, CA 94120
AI. 7.396
WALTER MAYER
316 W OAK
LODI CA 95240-3402
111611111111111111111111I11111111111111its 111111111I L n L dI
CITY CLLItK'S NOTE:
These documents were submitted
- on 06/28/02 by Walter Mayer for
Council review. Mr. Mayer has
dba AMER CAN MEDI CAL RESPONSE indicated that he will be providing
public comment at the Shirtsleeve
TRIP #. MOD -00035480-0I Session of July 2, 2002.
PATIENT NAME WALTER MAYER
DATE OF,SERViCE: 08/11/1997
AMOUNT DUE 133.35 INVOICE DATE;: 09/29/199
MOD0003548001 REMIT PAYMENT TO:
911 EMERGENCY
PO BOX 7423
SAN FRANCISCO,
;HARGE MY: ❑ VISA ❑ MASTERCARO
r ❑o 10000 aoaoao❑❑ EXPIRATION DATE a�❑❑
RE
PLEASE ENTER AMOUNT PAID:
PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT
SERVICES INC
CA 94120
-• PATIENT NAME
ACCOUNT NO:> "
`' ' TRIP NtJ: ;:;�:'=:`.';�:
? INVOICtDAT . =-
TER MAYER
t 000123571-0001
MOD -00035480-01
09/29/1997
OF SERVICE
11.00
SERVICE FROM
165.00
-
11/1997
316 W OAKS
.00
ODI
MEMORIAL HOSPITAL
IMPORTANT MESSAGES% Al, : s- ?r1!�'•-'- .
have billed your secondary insurance as a courtesy. This
punt still remains your responsibility. Unless we receive
.lent within 30 days of this invoice, the full balance of
s account will be due and payable by you.
)DE DESCRIPTION UNITS
UNIT CHARGE
TOTAL CHARGE-. ,
70 ALS BASE 1 _
519.00
519.00
90 ALS MILEAGE 15
11.00
165.00
99 EMERGENCY 1
.00
.00
22 OXYGEN 1
41.00
0 41.00
98 EKG PAPER 1
.00
.00
41 EKG MONITOR 1
.00
.00
94 INFUSION SET W/SWAY 1
.00
.00
94 INFUSION SET MICRO 1
.00
.00
y4 I.V. START PAK 1
.00
.00
15 NEEDLES, ALL 1
.00
.00
99 02 MASK/CANNULA 1
.00
.00
70 IV MAIN SET UP 1
.00
.00
*** OTHER CHARGES ***
.00
.00
*** PAYMENTS ***
533.41 -
ADJUSTMENTS ***
58.24-
4SPORT REASON: T11 ILLNESS TOTAL CHARGES DUE 133.35
RCVD: 17:30
;NOSIS: 7807 78702 78703
SEE REVERSE SIDE FOR INSURANCE INFORMATION /
Send billing inquiries to: American Medical Response, P.O. Box 7423, San Francisco, CA 94120
TIDER# : ZZZ89622Z FED TAX ID: 94-1736160
Number: 1-800-913-9106 Keep this portion for your records. Local Number: 1-209-238-4710
�!-• 1 i • • a. w . Vi J
i J
American Medical Response
P.O. Box 7423
San Francisco, CA 94120-7423
0 0 01 2 3 5 71
AMOUNT DUE
101 .47 ;INVOICE':DATE 09/03/199
WALTER MAYER MOD0662281100 REMIT PAYMENT TO:
316 W OAK
LODI, CA 95240 AMR WEST - VALLEY
PO BOX 7423
SAN FRANCISCO, CA 94120
A CHARGE MY: ❑ VISA ❑ MASTERCARD
-UNT ❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑ EXPIRATIONDATE ❑❑❑❑
n,TURE PLEASE ENTER AMOUNT PAID: $ /
PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT
PATIENT NAME
;.ACCOUNT NO::..
TRIP NO. INVOICE.'bATE::
4LTER MAYER 000123571-0001 MOD -06622811-00 09/03/1996
..
TE .OF,SERVIGE SERVICE FROM SERVICE TOr'.; .
5/09/1996 316 OAK LODI MEMORIAL HOSPITAL
IMPORTANT MESSAGES
e agree to hold your account for 10 days. As of the above
ate, no payment has been received. The balance of this account
s due and payable upon receipt. I£ we do not hear from you
mmediately, further collection activity will occur.
CODE DESGRIFTION
TOTAL.;
UNITS
UNIT;CHARGE
.:TOTAL CHARGE.
0370 ALS BASE
1
519.00
519.00
0390 ALS MILEAGE
1
11.03
11.03
0002 NIGHT CHARGE
1
61.00
61.00
0422 OXYGEN
1
58.00
58.00
7070 IV MAIN SET UP
1
.00
.00
0398 INFECTION CONTROL
1
.00
.00
0999 OXYGEN MASK NON BREA
1
.00
.00
0394 I.V. START PAK
1
.00
.00
7050 NORMAL SALINE INFUSI
1
.00
.00
** PAYMENTS ***
405.90
*** ADJUSTMENTS ***
41.66
141.66-
TOTAL CHARGES DUE..101 .4
RANSPORT REASON: T11 ILLNESS
ALL RCVD: 18:32
IAGNOSIS: 7802 7808
SEE REVERSE SIDE FOR INSURANCE INFORMATION
Send billing inquiries to: AMBULANCE BUSINESS SERVICES P.O. BOX 7423, SAN FRANCISCO, CA 94120-7423
ROVIDER# : ZZZ89622Z FED TAX ID: 94-1736160
ie Number: 1-800-913-9106 Keep this portion for your records. Local Number: 1-209-238-4710
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February 13, 1998
Walter Mayer
316 W. Oak
Lodi, CA 95240-3402
Dear Mr. Mayer:
San Joaquin
Emergency Medicai Services Agency
A Division of Health Care Services
I appreciated the opportunity of meeting with you and Supervisor Barber in January to
discuss your concerns regarding the ambulance bill sent to you by American Medical
Response (AMR). The Emergency Medical Services Agency staff have had a chance to
review your case, by auding the medical record and speaking to the AMR staff
involved in your care. V1re have also reviewed our policies and procedures.
I have listed below your issues, and provided a response to each, based upon our
investigation. For some of the issues, there is a recommendation for action which are
also listed below. Give me a call at 468-6600 if you have any further questions or
desire clarification on any of the areas listed. Please note that the issues are listed in
the order you raised them and not by order of priority.
Issue #1: Why did the AMR ambulance arrive after the fire department?
Shouldn't the fire and ambulance arrive simultaneously?
The ambulance and fire department are dispatched simultaneously but generally do not
arrive simultaneously because they respond from different station locations. Lodi Fire
Department is the first responder for your neighborhood and typically arrive first
because they have units dispersed throughout the city. As first responder, Lodi Fire
`^Deproent's job is to oinitially stabilize the patient, provide basic resuscitation and initial
basic life support care (maintain E a—T airway, circulation and scene stabilization).
Although the ambulance is dispatched simultaneously, it typically arrives after Lodi Fire
Department. There are times, however, where the ambulance arrives prior to the Fire
Department. The difference is based on unit location at the time of the call.
Issue #2: EMT Pollard inserted an IV without my consent.
Before proceeding to answer this questions, let me point out that the paramedic who
cared for you is named Julie Ballard. We discussed the case with Paramedic Ballard
and Dr. Marc Krueger, Medical Director for the EMS Agency. Dr. Krueger reviewed the
appropriateness of the care rendered.
mac- i020 , -cccxtcn, Cahfc: -;, iSZv^i
Walter Mayer
Page Two
When questioned, Paramedic Ballard says she explained her reasons for the need for
the IV and that she explained and that she obtained your consent prior to inserting an
IV, but she acknowledges that you initially did not agree to it. In regards to the
questions of whether or not the IV was appropriate, Dr. Marc Krueger evaluated your
care by reviewing the Prehospital Report form. According to the documentation,
Ms. Ballard found you pale. sweating and `vomiting violently". In addition, the EKG
monitor indicated a heart rhythm that was not stable. Dr. Krueger states the opinion
that the IV was appropriate given your weakened clinical condition and given your heart
rhythm. Dr. Krueger feels that according to the County's paramedic treatment protocol,
drug therapy through an IV access point was appropriate. Dr. Krueger concludes that
the paramedic level of care provided was appropriate and the ALS charge was also
appropriate.
Recommendation: Based on the review, several things are apparent. Mr.
Mayer, you do not feel you had given consent which is at odds with Paramedic
Ballard who feels you gave consent. Dr. Krueger feels that an IV was
appropriate therapy given your clinical condition and that the care was in I� 'r
compliance with County policies and procedures. There is no evidence that N M-1,4';
Paramedic Ballard had any financial interests in starting an IV and that her
reasons for starting it were only to assist you. Based on this, my conclusion is
that the ALS care and charge were appropriate and that AMR paramedic staff
performed appropriately. But, in consideration of your strong feelings about this
issue of consent, I requested and AMR voluntarily accepted the request to
reduce your ALS base rate charge to a BLS base rate. This means a refund of
$166 ($519 minus $353) to you. Because Medicare and your private insurance
have already paid for this ambulance bill, the check will be made out to you. You
may wish to make any adjustments with your insurance carriers.
Issue #3 Why doesn't the driver of the ambulance know how to get to Lodi
Memorial Hospital?
The total distance to the hospital was 1.4 miles. The AMR staff says getting to
the Hospital was not an issue. They do not recall asking you for directions.
Issue #4 The mileage charged to you was incorrect. You were billed for 15
miles. instead of 1.5 miles. In 1996. you had a bill reflecting a charge of $11.03.
This time you were billed $165.00.
AMR acknowledges that you were overbilled for mileage. They believe someone
in the billing office missed the decimal point. Your bill needs to be adjusted by
$143.00.
Walter Mayer
Page Three
Recommendation: AMR will issue a refund/adjustment to you in the amount of
$143.00 to reflect the overcharge on mileage. Since your insurance company
and MediCare have already paid for the bill, you may wish to make an
adjustment with them.
Issue #5 The ambulance bill had no local contact for questions - instead there
were 800 telephone numbers. as well as addresses in other, non San Joaquin
County cities. When you tried to get information from the ambulance stations. no
one was there.
EMS Agency staff has in the past and again recently discussed with AMR the
need to have a local contact for patient questions regarding ambulance bills. As a
result, AMR has moved staff to San Joaquin County to handle the initial billing of calls
originating in San Joaquin County. They are also available to answer questions. EMS
Agency staff also suggested that a local number be listed on the bill so as not to
confuse the public or patients. If that is not possible, then the telephone number listed
must be answered by individuals who can effectively deal with the patient's questions
for their locality, rather than give a �"cor,2ora nswer. The complaint noted to AMR is
that there is no local recourse india-M"t;an purs-ub, based on the information given in
the bill alone.
Recommendation: AMR is looking into ways to make the local staff that are
based within the County to be more available to answer questions. AMR staff is
investigating how that can best be done (e.g. bill, phone book, advertisements,
station information, etc).
Issue #6 When you found finally were able to find AMR staff. the staff (Pat
Christian) appeared initially to be unwilling to share the fee structure for the
company. In addition he was not able to clearly answer Vour question regarding
the difference between a BLS and ALS charge.
Pat Christian recalls speaking with you at the Station. He indicated he was
willing to help you and was saddened to hear that he did not answer your questions in a
satisfactory manner.
Issue #7 Concern that AMR is the only ambulance provider in the County,
which creates a monopoly situation in the County.
Currently. AMR is the largest ambulance provider in the County. In addition,
there are four other ambulance providers: Manteca District Ambulance, Escalon
Community Ambulance, Ripon Fire Department and A-1 Ambulance. All of these four
providers are separate from AMR. AMR has become the largest ambulance provider in
Walter Mayer
Page Three
the County because of mergers of ambulance providers over the past six years. The
County is not allowed to grant a monopoly without going through a bid process.
Your comments are appreciated, and will be used to make improvements in our system.
Please let me know if I can answer any further questions for you.
Sincerely,
Elaine L. Hatch
EMS Director
Permit Officer Designee
/dl
MAYER
cc: Supervisor George Barber
Michael N. Smith, Director, Permit Officer
EMS
13 May 2002
Walter Mayer
316 W. Oak
Lodi, California 95240-3402
Dear Mr. Mayer:
San Joaquin
Emergency Medical Services Agency
A Division of Health Care Services
I enjoyed speaking with you the other day in my office. Your comments regarding the possible lack of reimbursement
of the previously discovered billing errors for service in 1997 (Trip 9 MOD -00035480-01) were troubling. American
Medical Response had assured me reimbursement occurred. After our meeting I contacted AMR and requested they
provide proof of payment.
Attached are copies of checks written by AMR to refund your insurance companies for the billing mistakes identified
during our investigation. The refund to your insurance companies instead of you is appropriate since your insurance
paid for your transportation expenses. Above each check is the trip number, previously identified above, that links the
reimbursements to your specific invoice (copy attached). The reimbursement covers both the mileage overage and the
adjustment in service from Advanced Life Support (ALS) to Basic Life Support (BLS).
I hope this additional documentation addresses your concerns. Peel free to give either Darrell Cramphorn or myself a
call if you have further questions. I may be reached at 209 468-6610 and Darrell's telephone number is 468-6818.
Sincerely,
Elaine L. Hatch
FMS Director
WalterMayer05-2002
cc: Jack Sieglock, Supervisor
Roger Speed, Director, Health Care Services
Darrell Cramphorn, EMS Coordinator
Enclosures
P. O. Box 1020 • Stockton, California 95201 • 209-468-6818
sjemsa@co.san-joaquin.ca.us 9 www.co.san-joaquin.ca.us/ems/index.htm
03/,15/02 FRI 11:55 FAX 303 614 8755 AMR AP
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P.,
THE ADVANTAGES OF IMPLEMENTING A PUBLIC
SECTOR BASED ALS PROGRAM
A POSITION PAPER
Presented to Bob Moreno
California State University, Long Beach
In Fulfillment
Of the requirements for the course
OCST, Independent Study
By Jeff S.Larson
BS, 2002, CSULB
March 2002
My objective is to research and evaluate the options for establishing a public
sector based Advanced Life Support (ALS) program or paramedic engine company
system within the City of Lodi, California and make a recommendation. The role of the
fire service is drastically changing. Major events such as 9/11 or common everyday
occurrences like a house fire have a major impact on the public sector when it comes to
delivering one of it's services, fire protection. Under the umbrella of fire protection
comes many things, such as trench, low and high angle rescue, hazardous materials calls
vehicle extrication and the like. Originally volunteer companies were established to
reduce fire loss in the local community. As time progressed insurance companies were
established and started paying people to put out fires on homes with their firemark. That
was the beginning of fire service in this great nation. What I am talking about occurred
within the last three decades. The advent of emergency medical calls being handled by
the public sector basically began in the early 1970's. It occurred mainly, because firemen
were considered the jack of all trades. If one did not know what to do in an emergency,
one would call the fire department for help. Beginning in the mid 1970's Los Angeles
County Fire Department began a new program of providing paramedics at the scene of an
emergency. These paramedics would provide an advanced level of medical care in the
field. This has transformed from something we also do, into a major role for the modern
fire service. In January of 1972 a new television show was aired. This program, as stated
by Ludwig (2000) "Emergency had a dramatic impact on the development of EMS and
the shaping of the careers of many people". This show affected how millions of people
viewed the fire service. This in turn had a large impact in the development of EMS in the
US. In most communities emergency medical calls encompass between 60% and 80% of
all emergency calls. In the city of Lodi 69.25% of all calls were emergency medical calls
in calendar year 2001. According to the of the San Joaquin Emergency Medical Services
Agency (M. Voelker personal communication) approximately one half of all emergency
medical service calls are ALS based. The provider of this service must be able to support
this high volume of calls, provide a high level of service, competent employees, rapid
response times and have a reasonable cost associated with the service provided. Who is
best prepared to provide these above-mentioned items to our community? Is it the private
sector or fire department based ALS service? More specifically what are the advantages
and disadvantages of fire service based paramedics providing ALS to the community?
The advantages and disadvantages are many, so much so that they co -mingle quite
frequently. They encompass the gamut. The examples are numerous and the following is
a partial list of some of these advantages and disadvantages. Fire based ALS would
supply faster response times, fire ALS would assist with justification of existence,
services would not require any additional associated cost to the patient, there is a certain
level of expectation by the community that the fire department provide medical care.
There is an increased value to citizenry by individuals cross -trained to do many tasks. If
transport were provided, there would be an increased number of ALS units if the private
provider remained. Excess revenue would be placed in the general fund and would go
towards community projects. Having a current structure in place would help reduce the
costs for the increased level of service. There is a certain level of trust that the
community has for the fire service. EMS providers are required by law and by patient
expectation to provide appropriate medical treatment to any patient who needs it
(Becknell and Ostrow, 1996). Accepted response practices would utilize a fire apparatus
to respond to most medical emergencies. Since they are responding, does it not make
sense that they provide the highest level of care possible? One of the negative impacts is
a large initial investment and recurring costs if the ALS provider does not provide
transport. In this scenario or option number three of Lodi's plan, paramedics would be
placed on the engine companies and not initiate transport. The initial outlay would cost a
little over one million dollars. This large capital outlay would only actually directly
affect between 2%-8% of the community's constituents annually. The primary item to
remember is that even if you do not transport you have raised the level of service you
provide to the community. If you provided transport, the possibility of the existing
provider remaining would reduce revenue streams through sharing of transport
responsibilities. You would be responsible for transporting patients out of town, thus
possibly reducing staffing levels within the city. This is countered by the fact that you
would have additional personnel on duty each day. Funds made through patient transport
would not go directly back to the fire department. They would go directly to the General
Fund. Menkin, (1996) stated that managed care organizations look for providers that
offer full service, cost effective medical care. Consequently, a single dimensional EMS
provider that can run only ALS calls will be a clear loser. There is always some difficulty
in collecting funds; hence a low collection rate and a lack of business experience make it
difficult for fire service managers to compete with private industry who have been in the
business for tenure.
Fire life safety procedures such as Building and Fire Codes, fire resistive
structural members and components, sprinkler systems, advanced water delivery systems
and highly trained firefighters have reduced the number of fatalities over the past decade.
The average annual loss of life in the US in the 1960's was around 10,000 people
annually. This rate has been declining fairly steadily since the 1960's. Currently the
average annual loss of life is between 4,000 and 5,000 people. This factor along with
others has required the fire service to glimpse into different arenas to justify our
existence. Exactly like any other business, we must turn a profit. The profit, in fire
service is not always tangible, like money. We are service oriented and must provide a
needed service to justify our existence. In the debate between the private and public
sector regarding who should provide EMS services, there has been little if any concern
for patient care. The emphasis has been on how much money could or might be saved
(Brame, 1995). When it should be placed on how many more lives might be saved or
how might we improve the standard of care. In many instances we should not try and
convert the services rendered into a dollar amount, rather we should attempt to assess the
return on investment. For example, a competent ambulance unit arrives on scene with a
paramedic on board under the local governing jurisdictions allotted time. They then
charge the insurance company for their services. Unfortunately, that loved one is lost to
cardiac arrest. Now, take that same scenario with a few adjustments. The local fire
department has just spent one million dollars hiring and training paramedics, securing
ambulances and equipment. They respond to the call. Since there are more available
units in closer locations they arrive in one half the time. The fire department paramedic
on board the engine or ambulance intubates the patient, shocks him with an Automated
External Defibrillator and dispenses pharmacology. This patient is converted because he
was still in ventricular fibrillation when the fire unit arrived due to their reduced response
time in comparison to the private ambulance provider. They are released from the
hospital two weeks later. How much was that citizen's life worth? Was it worth a partial
amount or the whole one million dollars? Who sets the amount? Society associates or
perceives something as valuable, at what point is it more valuable than money? It is
when life is involved directly. The question now is not to ask was it worth it. The
question is how do we calculate the return on investment. For a private ambulance
provider it is a return on investment if they turn a profit and can stay in business. For the
fire service, it is a perception to the governing body and the citizens to whom they
provide this valuable service.
Times of recession and budget cutbacks require all the more that the fire service
be able to justify it's existence with a multi tasked work force capable of handling the
many facets of emergency services. Firefighters trained to the level of paramedics would
provide the community with an increased level of service with a minimum amount of
cost. A large capital outlay is needed and can be offset if transport is provided by the
providing agency. However, if an agency does not transport you must quantify the costs
versus the services provided. An article by Jack Stout (1987) lists seven advantages of
paramedic engines. Among those, he states, "ALS engines are our industry's least
5
expensive means of rapidly delivering paramedic capability to the scene". Additionally,
he states that the "use of ALS engines improves the productivity of the entire fire
department" and that "crews working ALS engines are not just cross trained, they are also
cross utilized every day". It is this type of training that brings the fire department engine
companies to utilize the capabilities of their personnel to the fullest. This is done with a
minimal amount of resources while returning a valuable asset. The structure of the fire
department hierarchy is in place, including modes of transportation, with a little training
and education a multi -faceted and capable firefighter can become a paramedic. When
you transport, billing of the insurance companies can offset these costs. Some citizens
are afraid of this billing. They believe that they might be getting double taxed. This is
actually not the case. The service provided will be billed to the insurance companies for
compensation, not to the private citizen. The fire department is mandated by law to
respond to these types of incidents. Does it not make sense to provide the highest level of
service available to the community, since fire units are responding nonetheless? In a
research paper by Fiero (1990) the benefits of utilizing paramedic engine companies in
the delivery of emergency medical services was reviewed. In that paper with the use of
fire based ALS service, the community was given he noted "a more productive and
effective use of emergency personnel, reduced operational costs, and improved services
to the community at lower costs". In regards to ALS engine companies Stinette (1994)
noted that the advantages of a paramedic engine company are: "cost effectiveness, a
reduction in response times, increased productivity, increased level of staff for fire
apparatus, and greater flexibility in providing service". What is needed is the expansion
of services by the public sector to make existing services more valuable to the taxpayer
(Thorp, 1997). Opponents of privatization and public-private competition often cite that
such methods rarely reduce government costs. However, more than 100 studies in the last
20 years have documented cost savings (Thorp, 1997). Thus proving that an ALS trained
multi faceted firefighter provides the taxpayer with the most bang for their buck. The
M
firefighters who work in the community generally speaking have a higher regard for their
community. They are giving back to their community, whereas a private provider is a
generally a large conglomerate or Fortune 500 company, with it's headquarters outside of
the US for tax purposes. The fire service must halt the fragmentation of services by the
private sector (Thorp, 1997). In order for the fire service to sustain in this ever-changing
environment it must increase its public service to the community. Providing ALS is one
of those avenues to achieve that goal.
The concept of providing a multi -faceted, cross -trained worker is nothing new in
this country or society. The last quarter century has seen many companies emerge solely
to provide businesses with consultation on how to ascertain more productivity from their
employees. The fire service is in the business of getting productivity from our
employees. We are cross -trained, multi faceted and provide a service that most others do
not desire to do. The training we have received has provided us with the tools to provide
a better service for the community at a lower cost. If we do not provide adequate service,
we are no different than any private business, another agency can come in and contract
out their services and put us out of business. Is that in the best interest of the community?
Generally speaking, the answer is no. Through reduced operational costs, reduced
response times and with a hierarchy that is already in place this appears to be a logical
step for the fire service to take. Reduced response times are a major consideration in
providing ALS care. Lodi Fire Department would provide a minimum of three
ambulances in the city strategically located while, AMR would have between one and
three dependent upon the situation. The start up costs of the program in Lodi would be
approximately $1.2 million for twelve paramedics and one administrator. According to
Patrick Ho (Ho, 2002) utilizing a financial model including; standard collection rates
coupled with the purchase of equipment, supplies and overhead costs, the City of Lodi
Fire Department would generate approximately $103,000 in revenues annually. These
numbers would be slightly reduced if AMR remained and provided joint transport. The
cost of the programs, whether fire or privately based is basically the same. Firefighters
have a tie to the community and the revenues would return to the community in the form
of street lighting, art, or sidewalks for community improvement. In the case of private
industry that revenue stream goes to the shareholder that only cares about their dividends.
International Association of Firefighters President Alfred Whitehead (1996) states
that "whether for fires or medical emergencies, the only way to assure quick and effective
response is to have units close to the scene of the events". "As many communities have
discovered, the way to handle these needs is to upgrade engine companies to ALS
paramedic engines." He continues on to state that an International Association of Fire
Fighters study of the different methods of delivering EMS "determined that ALS engine
companies have a faster response time than ambulance based EMS, while posting no loss
in fire response time or fire suppression capabilities".
Can we truly and honestly justify an increased level of service to the community
at this cost? The answer is yes, definitely yes. The scales are askew; the good far
outweighs the negatives. This increased level of service will have a definitive and
positive impact on this community, an impact that is well worth the cost.
Reference List
Becknell, J. and Ostrow, S. (1996, March). Providers' primer on managed care.
Jems, 81-86.
Brame, K. (1995, May) Bankruptcy of both money and values, Fire Chief, 24-27.
Fiero, J. (1990, August). Refining fire and EMS services using paramedic
companies. Executive Development Research Paper, 11 Emmitsburg, Maryland:
National Fire Academy
Ho, P, (2002, January). Financial model and economic feasibility study, Allied
Information and Services, Sacramento, CA. 3
Ludwig, G. (2000, April) Project 51: Celebrating the origin of fire service EMS,
Firehouse, 28.
Menkin, H. (1996, May). Understanding Managed Care. EMS Insider, 6,7.
Stinette, E. (1994, May). A research effort to determine issues and trends involved
with improving an ALS delivery system. Executive Development Research Paper, 12
Emmitsburg, Maryland: National Fire Academy
42
Thorp, F. (1997, May). What is this thing -service? Responder, 7, 27
Voelker, M. (personal communication, February 7, 2002)
Whitehead, A. (1996, April) Fire based EMS makes sense. Fire Chief 40 (4),40-
9