Special thanks to JP Peterson at MEDIC in Charlotte, NC for agreeing to share their experiences with this reporter…
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Knox County's struggling ambulance service will change. What will that look like?
Tyler Whetstone
October 25, 2023
https://www.knoxnews.com/story/news/local/2023/10/25/knox-county-struggling-ambulance-service-will-change-under-new-contract/71204237007/
Knox County doesn’t pay a dime for the private ambulances that serve sick and injured people, but lengthening response times have leaders rethinking whether they need to spend public money to fix the problem fast.
The only solution could require an annual investment of a few million in tax dollars, and that decision is looming. Knox County commissioners will decide in November on a new emergency services contract.
The stakes are high, especially for the injured or sick waiting for help to arrive.
County leaders might have to get creative to ensure reliable ambulance service, especially in an American health care system where too many patients rely on emergency rooms for care that should be provided in clinics, and hospitals operate with razor-thin staffing and under tremendous pressure to generate income.
A consultant hired to review the local situation, Fitch & Associates, said the soon-to-expire contract with American Medical Response is "financially nonviable." A Fitch representative told commissioners Oct. 16 the county likely will have to subsidize any contract by paying $1.9 million to $3 million each year.
With ambulance response times in Knox County often topping 17 minutes for the most serious calls such as trauma, heart attack and stroke, patients and health care professionals are sounding the alarm.
So, too, are Knoxville firefighters and cops who are often first to arrive when a person is in distress but limited by law and training in what care and transport they can provide. This month, Knoxville police spokesperson Scott Erland described the situation to Knox News in no uncertain terms.
“The harsh truth is that, in the current state of ambulance services in Knox County, there’s no guarantee an ambulance will show up quickly or at all," Erland said, "leaving residents who need urgent care in a situation where they potentially have to find their own way to the hospital.”
In order to understand the county's options, Knox News analyzed ambulance service in two counties grappling with similar challenges: Hamilton County, home to Chattanooga, and Mecklenburg County, North Carolina, home to Charlotte. Both operate their own EMS systems, but there are insights to bring to Knox County's problems.
Here’s a look at where we are and where the county can go from here.
Knox County increased allowable response times
Knox County’s ambulance service is provided by American Medical Response, or AMR. The contract originally set response time goals of 10 minutes or fewer on any call 90% of the time.
But as market conditions changed, the contract was adjusted to give AMR 17 minutes to arrive for any call.
Even with the extension, ambulances are unlikely to come that quickly, especially once you leave the Knoxville city limits.
In 2022, outlying areas, including Corryton, Farragut, Mascot, Powell and Strawberry Plains, had a response time more than 17 minutes on priority one calls (which are the most life-threatening situations) 90% of the time. Knoxville was the only place with call times of less than 17 minutes 90% of the time ‒ and it barely hit that mark.
Outside of Knoxville, ambulances arrived in other places on average between 18.5 to 26 minutes after a call for help came in, according to data provided in the Fitch review.
Proposal for zoned response would reduce response times - at a cost
Ambulances are required to serve the entire county, but Fitch proposed splitting the county up in zones centered on the city, on North and East Knox County and on West Knox County and Farragut.
Dividing Knox County into three zones, one covering the city of Knoxville and two covering the rest of the county outside city limits, could reduce response times. Those who live outside the city, however, still could wait up to 20 minutes for even the most serious medical emergencies.
In that zone structure, the county could implement a system designed to provide emergency medical services response times under 10 minutes for 90% of calls from Knoxville residents, and under 20 minutes for 90% of county residents outside city limits.
This proposal is expected to cost upwards of $3 million and would be more expensive if responses were reduced further. For example, a 10-minute urban, 15-minute rural response time would require more EMS resources and would be more expensive.
Learning from Hamilton County
Hamilton County is a slightly smaller mirror of Knox County, both in population and its urban/rural divide. The county has run its own EMS system since 1988 and offers a few ideas to emulate.
The county’s average response time is 10 minutes, EMS director John Miller told Knox News. Like Knox County, Hamilton County deals with extended "wall times," the insider term for how long ambulance crews have to wait at a hospital before the patient they brought is admitted.
Recently, Hamilton County has pushed back on emergency room wait times with an offload policy that allows them to simply leave patients inside an emergency waiting room. The policy is included in their agreement with local hospitals.
“It’s not the hospitals’ fault, but we can’t have five trucks waiting two hours,” deputy director Wade Batson said. “(Hospitals) don’t like it, but at the end of the day, something has got to give.”
AMR sometimes does this now, but staffers are more likely to group a few patients together at an ER with a single employee watching them.
Hamilton County's costs track with Knox County's expected bill
The Hamilton County-run ambulance system costs about what Knox County will likely end up paying. Hamilton County budgeted $17.9 million for EMS for the 2023 fiscal year but softened the financial hit by using $15.7 million in expected revenues from ambulance service, paid mostly by patients' insurers. The direct cost to taxpayers is $2.2 million.
But those are the annual costs to operate a system that already exists. Starting one up means buying ambulances and hiring more skilled staffers.
New ambulances, for instance, take at least 18 months to arrive after they're ordered and cost more than $300,000 apiece, according to the Fitch review.
Charlotte metro wait times have gotten longer … and leaders brag about it
Earlier this year, leaders in Mecklenburg County, North Carolina, turned their EMS system on its head. The county’s EMS system serves more than 1 million people, more than double Knox County's population.
The door to change was already opening as costs started to outpace revenues. Mecklenburg EMS Agency executive director John “JP” Peterson told Knox News the COVID-19 pandemic blew open the doors of possibilities for rethinking ambulance service.
In April, the county switched to a system that relies heavily on triage dispatch to determine the severity of the patient's medical condition. If the condition is potentially life-threatening, an ambulance is expected to arrive in less than 11 minutes.
In less-severe cases, responders are given a cushion. The scaled system goes from 11 minutes to 15 to 30 and finally, for those who need assistance but not right away – think about sprained ankles – EMS has up to one hour to arrive.
Peterson said the county previously dispatched ambulances for potentially life-threatening emergencies about 75% of the time, but those cases turned out to truly be life-threatening just 5% of the time. About 35% of patients didn’t need to go to the hospital at all.
“The public sometimes doesn’t realize that everyone who calls 911 isn’t experiencing a life-threatening (event). … We have to pivot and do a combination of readjusting our system response (and) educating the public,” Peterson said.
This type of dispatch depends on a near-perfect triage system, where trained professionals can take calls and quickly work through a sometimes lengthy set of questions to determine whether a person needs immediate assistance.
In the months since Mecklenburg County implemented the new system, dispatchers have classified 30,000 calls as low priority. That means an ambulance crew has up to an hour to respond.
Of those calls, less than 1% needed a quicker transport, Peterson said, and there have been no deaths or averse outcomes from the new policy.
Knox County will likely copy the triage system in some way. In its proposal for Knox County, Fitch & Associates suggested some sort of tiered response system based on the severity of call.
Peterson says the new policy is a bright spot amid constantly increasing EMS costs, though there’s admittedly a very long way to go.
“If all of this is successful, then in the future, maybe 5 to 10 years from now, hopefully we will need less resources to do the work," he said.
"But that’s pipe dream, down-the-road thinking.”
What can you stand? What can you pay?
Matt Zavadsky is an EMS expert for the Center for Public Safety Management and the chief transformation officer at MedStar Mobile Healthcare, which operates the EMS service in Fort Worth, Texas.
In Fort Worth, emergency crews responded to 450,000 911 calls over a 3-year period and just over 2% of calls required lifesaving care. The rest of callers, he said, don't need an ambulance within the nine minutes he defined as an immediate response.
The choice for how the system should be shaped is entirely up to the community and what it’s willing to accept, Zavadsky told Knox News.
Will we demand 9-minute response times? Are 20-minute response times OK?
The fewer the minutes it takes an ambulance to arrive, the more money it costs taxpayers.
You end up settling on “what your heart can withstand, and your wallet can bear,” he said.
So many factors have led to a broken system
Everyone from experts in the field to county officials running the process agrees the system is messed up regardless of what model is used.
The challenges include many out of the hands of public officials, such as an increasing reliance by patients on emergency rooms for primary care best provided in clinics.
Zavadsky, the Fort Worth official, has seen firsthand that EMS costs have skyrocketed “50-70%” since 2020, much of it in additional personnel costs. Employees have received a 58% increase in wages in the past 18 months, he said.
“The primary driver in that is personnel. When COVID happened, EMTs making $17-20 an hour figured, 'Maybe this isn’t worth risking my life for,'” he said. “Then you had the nursing shortage and hospitals' desire to hire EMTs and paramedics to work there for half of what they pay (nurses).”
