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Commentary: Multnomah County (OR) Ambulance Crisis: By Design or Mistake?

20 Jun 2024 8:32 AM | Matt Zavadsky (Administrator)

Interesting perspective... Community and EMS system leaders should carefully evaluate current evidence-base practices and re-design EMS systems for success and sustainability.


Multnomah County (OR) Ambulance Crisis: By Design or Mistake?

Multnomah county has turned a contracting failure with AMR into an ambulance crisis, writes Stephen Dean, PhD.

Stephen Dean, PhD



The Failsafe Franchise

EMS pioneer Jack Stout created the Failsafe Franchise in the 1980s when he was hired to fix the ambulance service in Fort Worth, Texas. He designed the model to produce clinical quality and economic efficiency through contract provisions that use competition in the wholesale market to ensure the lowest cost; and then make available an ingenious set of provisions to hold the winning ambulance bidder accountable for the promised performance.5

The Accountability provisions are designed to ensure that should an ambulance provider be unable to perform, it can be replaced overnight without any degradation in service to the patients. The Failsafe Franchise ensures accountability through two key contract provisions: first, the 3 Way Lease, and second, the process to determine if an ambulance provider has failed to meet its contractual obligations.5

The 3 Way Lease

Jack Stout was the first person to use the 3 Way Lease in EMS contracting. It simply requires a contractor to lease all its ambulances and equipment in a manner that allows the contracting entity to acquire all this equipment by assuming the lease payments if the contractor is terminated. This arrangement prevents unscrupulous ambulance companies from holding patients hostage by threatening to abscond with the system’s infrastructure if the company is replaced.5

Contractor Due Process

The second innovation protects the ambulance provider along with ensuring accountability, by providing due process in the form of required notifications of violations of contract provisions as well as opportunities to provide correction plans to fix violations. The replacement of an ambulance provider through the declaration of “material breach” is the county’s ultimate tool to ensure accountability.

Jack Stout advocated for the use of private ambulance companies because, unlike fire departments or publicly operated ambulance services, they could be replaced. He famously, or infamously, said the biggest advantage of using a private company is that they are easy to fire if they do not perform. 

Failed Bid Process

In 2018, the Multnomah County (OR) Health Department conducted a competitive bid using a Failsafe Franchise system design. AMR was the incumbent provider with a history of more than 20 years providing eight-minute response times with 90% reliability to life threatening emergencies with Advanced Life Support (ALS) ambulances staffed with two paramedics each, as required by their contract with the county.4

In addition to those requirements, the request for proposal (RFP) contained over a hundred other requirements and deliverables including live monitoring of the system and reporting of response time and clinical performance.6 With no indications that the county was in the least dissatisfied with the incumbent provider and such a daunting list of clinical demands, there was only one bid submitted, that of the incumbent.7

When AMR and the county completed their negotiations to set the rates patients would be charged by AMR, the rates were the highest in the county’s history. The county agreed to an immediate 34% increase in rates and annual rate increases based on the CPI of up to 5.5% per year. These annual rate increases were automatic and not dependent upon AMR even meeting the minimum standards in the contract.7

By attracting only one bidder, the county effectively negated the provisions for obtaining a competitive rate.

Including the initial 34% rate increase, ambulance rates have increased by 70% since the county entered its contract with AMR in 2018. For the past two years patients have seen rates go up even though the county and AMR both agree that the service patients are currently receiving is substandard.8

This bid failure should have been a warning to the county that should AMR fail to perform, it might be difficult to find another provider that could meet the county’s stringent standards, particularly its unusual minimum staffing requirement of two paramedics per ambulance rather than one paramedic and one EMT.

Contract Renewal Failure

While AMR remained in compliance with response time standards in late 2021, it had become evident that increasingly longer response times were occurring because of a staffing shortage that was getting worse each month. The county had an opportunity to address this issue, and rate issues, with AMR prior to the expiration of the AMR contract in August of 2023.6

Though the original contract had a five-year term, it allowed the county to make an offer of renewal at the county’s sole discretion. That renewal offer however had to be presented to AMR at least 18 months prior to end of the initial five-year term, making it due before March 1, 2022.

The county made the offer to renew 17 days late. The County Board of Commissioners (Board) held no hearing, received no briefing, and voted to approve the renewal on its consent agenda, where multiple routine or inconsequential items may be approved with one vote.9

The county’s EMS Office Staff submitted a misleading “Agenda Placement Request”10 which stated in part, “Contractually, if AMR performance measures are met, an extension of an additional five years shall be issued.”

According to the contract, however the request should have stated, “Contractually, if AMR performance measures are met, an extension of up to an additional five years shall may be issued.”6

Why the staff did not just copy the exact contract language is not officially known.

Commissioner Sharon Meieran, MD, JD, who has been an outspoken advocate for patient care and at odds with both the EMS Office and County Chair for their inept handling of the staffing crisis told the press, “The fact that renewal of the ambulance contract was done as a ‘consent agenda’ item is so bizarre as to suggest a conscious intent to hide this from the board. And it succeeded.”9

To date the EMS staff have not commented on the contract renewal or the misrepresentations during the process.

The renewal process was the county’s last opportunity to negotiate on equal terms with AMR about staffing and rate concerns that were, or should have been, evident from the increasingly longer response times each month due to the national paramedic shortage.

Instead, the Board approved the contract renewal on March 17 and just two weeks later, AMR was out of compliance with the contract’s response time standards, and has been ever since.11 The county threw away the opportunity to address staffing and rates in a renewal negotiation.

Failure to Fine and Failure to Replace the Contractor for Material Breach

The Failsafe Franchise contains two types of penalty provisions: fines for long response times; and replacement of an ambulance provider for major failures to meet contract standards, including repetitive failures to meet monthly response time standards.6

The fundamental problem causing the substandard response times is a lack of staffing for AMR ambulances. And the reason AMR lacks staffing is because it cannot retain, nor recruit, enough paramedics due to the ongoing national shortage of paramedics which started after the pandemic.8

Changing the staffing requirement temporarily to a minimum of one medic and one EMT would allow AMR to keep all its units staffed until the paramedic shortage ends because there is no shortage of EMTs. Every other county in Oregon allows ALS ambulances to be staffed in this manner as do all the surrounding counties in the state of Washington.12

The county has expressed concern that two paramedics are needed on cardiac arrests and that area first responders are not always able to send a paramedic to these calls. Requiring AMR to send two ambulances to cardiac arrest calls, however, would be simple enough with a fully staffed system.

There are approximately seven hundred cardiac arrests a year out of 120,000 responses. It also turns out that in 2022 fire paramedics were present at 99.9% of the cardiac arrests in the city of Portland where most of the county’s arrests occur. The sole exception was a witnessed arrest in an ambulance in route to the hospital. So, the actual number of two ambulance responses required would be much less than seven hundred.13

The county’s medical treatment protocols require rapid transport to the hospital of patients suffering from strokes, heart attacks, trauma, and childbirth complications for optimal care. The county monitors the length of time ambulances are on scene at these types of calls to ensure that patients arrive as soon as possible at the hospital to receive time critical care or surgical interventions. Long response times contribute directly to delays in getting these patients the care they require.14

Failure to Fine for “Outlier” Response Time Violations

The county had earlier started chipping away at the Accountability provisions of the system design by not fining AMR for dangerously long response times, referred to as “outlier” responses, starting in the first year of the Contract. The Contract defines these long response times for Code 3 (life threatening emergency) calls as 13 minutes or greater in urban areas and 25 minutes or greater in rural areas.6

The purpose of the outlier fines is to discourage AMR from providing extremely long response times to a few unlucky patients to maintain overall compliance.

AMR and the county cited the paramedic shortage in 2021 and 2022 as a reason for outlier response times. But by forgiving the fines for these long responses, the county created an incentive for AMR to scrape by on compliance at the expense of these few patients who received the very long response times.15

Failure to Declare Material Breach

According to the accountability provisions of the Failsafe Franchise, if an ambulance provider fails to perform, the contracting jurisdiction can replace the provider after notifying the provider of its failure to perform and offering the provider the opportunity to correct the failure.5

Repetitive noncompliance occurs if AMR fails to meet response time compliance three months in a row. If the company fails to correct the compliance the county can declare AMR in Material Breach and initiate the replacement of AMR with another provider. However, the county has “sole discretion” to determine “Material Breach,” so the county has leeway about whether, and when, to invoke these provisions.6

The county issued a notice of repetitive noncompliance in August 2023 after 18 months of noncompliance and after AMR’s corrective plan to improve paramedic recruiting and use basic life support (BLS) Ambulances to improve response time performance failed. The county notified AMR it would begin fining the company, as well.15

In November 2023, the county fined AMR over $500,000 for long response times that occurred in a single month, August 2023. The county’s Health Director also announced that the county was not interested in replacing AMR.16 AMR promptly appealed the fines to that same Health Director as specified in the Contract. He denied the appeal, but AMR has still never paid any fines.17

The county has not presented medical research or evidence that shows a benefit to patients of two paramedics over one paramedic absent rapid response times. In fact, the research presented by the county and AMR show the opposite, that response times are much more significant than the presence of a second paramedic.18

Failsafe Franchise or County to Blame?

The county had effectively abandoned the Failsafe Franchise system design by the end of 2023, including its provisions for guaranteeing low rates through bid competition and quality through its system of fines and provisions for contractor replacement.

In every instance, it was the county that circumvented or just ignored the safeguards in the model; the same safeguards which were incorporated into its RFP and contract with AMR, to guarantee performance accountability and fair, competitive rates.

After the summer of 2022, rates continued to increase annually even as AMR’s compliance with the standards upon which those rates were based continued to plummet. As personnel costs decreased by millions of dollars per year due to the staff shortage, there was an opportunity instead for AMR to reap enormous windfall profits.

The Board of Commissioners voted in February 2024 not to take immediate action to address the long response times and poor EMS quality that exists today but did approve a plan to study the problem over the next year.19 That plan also includes mediation with AMR apparently to prevent the implementation of the one medic, one EMT staffing solution proposed earlier by AMR which was endorsed by every EMS first responder organization and every city in the county.

County Commissioner Sharon Meieran expressed her frustration with the board’s inaction in December 2023.

I would just conclude then that the herculean effort to avoid talking about ambulance response and emergencies is mind-blowing to me, and I just watch it happening. And as a board, I think our responsibility is to hold the chair to account in terms of bringing things to the attention of the people for board meetings and allowing us to discuss what is literally costing lives of Multnomah county residents every day that you fail to act.20

The cause of the Failsafe Franchise model’s failure in Multnomah County is the Board’s forfeiture of its ability to hold AMR accountable. This is because the EMS medical director has refused to adapt the staffing standard to the reality of the national paramedic shortage in Oregon. AMR cannot be replaced, because no other ambulance provider in the country can simultaneously meet the county’s response time requirements while also meeting the county’s stringent two-paramedic staffing requirement.

To date, based upon the recommendation of the county’s EMS medical director, the county chair and two lame duck commissioners whose terms will end in December have blocked all attempts to change the staffing standard to address the ambulance shortage, the latest vote taking place on June 6, 2024. This vote affirms the continuation of the county policy of harming patients and enriching AMR.19, 21

Were just one of these four persons to change their position, the ambulance shortage could end, and contractor accountability be restored.

Editor’s Note: This commentary reflects the opinion of the author and does not necessarily reflect the opinions of JEMS. 


1. Watson, E., A Portland Man Died Waiting for an Ambulance that Didn’t Arrive for 32 Minutes:. 2023, KGW-TV: Portland, Oregon

2. Pederson, J.V., Chair Jessica Vega Pederson Announces Four-Point Plan to Address Ambulance Service Crisis. 2024: Portland, OR

3. Haas, R., AMR Pressures Multnomah County Over Ambulance Staffing Rules. 2024: Portland, OR

4. Lewis, M., Paul; Deputy Health Officer, Multnomah County, D.E.A. Knott, Multnomah County, and M. Oxman, Gary; Health Officer, Retired, Multnomah County. Multnomah County Emergency Medical Services Planning and Procurement Project Kickoff. [Web] 2017 2024/01/01 [cited 2024 January 11, 2024]; Available from: https://multco-web7-psh-files-usw2.s3-us-west-2.amazonaws.com/s3fs-public/EMS_project_kickoff_slides.pdf.

5. Stout, J., The Failsafe Franchise. Journal of Emergency Medical Services, 1985. 10(10): p. 56-58.

6. Multnomah County, O., Multnomah County Services Contract Agreement for Exclusive Ambulance Service Contract # 5600002522. 2018: Portland Oregon. p. 56

7. Multnomah County, O., Board Approves New Five-Year Contract for Ambulance Services. 2018, Multnomah County, Oregon: Portland, Oregon

8. Lewis, M., Paul, R. Lauer, and D. Schappe, Perspectives On Addressing Multnomah County Ambulance Delays Amid Staffing Woes. 2023, Oregon Public Broadcasting

9. Haas, E., ‘Consent Agenda’ Was Key to ‘Hide’ MultCo-AMR Contract Renewal. 2024: Portland, OR

10. Monnig, A., Multnomah County Agenda Placement Request. 2022: Portland, OR

11. Lewis, P. and A. Monnig, EMS Ambulance Services Briefing – September 19, 2023. 2023: Portland, Oregon

12. Legislature, O.S., Oregon Revised Statutes:  Chapter 682 — Regulation of Ambulance Services and Emergency Medical Services Providers. 2023: Salem, OR. p. 29

13. Haas, E., Paramedic Paradox: Unraveling Multnomah County’s Response Time Dilemma. 2023: Portland, Oregon

14. Jui, M., Jonathan; EMS Medical Director, Multnomah County, Patient Treatment Protocols  Section 10:  Treatment. 2024.

15. Pederson, J.V., Chair Jessica Vega Pederson: County Will Issue Penalties to Address AMR Performance Issues. 2023: Portland, Oregon

16. Pederson, J.V., Multnomah County fines AMR $513,650. 2023, Multnomah County Executive: Portland, OR

17. Del Savio, A., Tensions and Wait Times Rise During Multnomah County Ambulance Shortage. 2024, Pamplin Mediaw

18. Watson, E., Why Ambulance Provider AMR Says Multnomah County’s Emergency Medical System Is in a State of Crisis. 2023, KGW-TV: Portland, Oregon

19. Haas, E., ‘Sinking Ship’: MultCo Board Votes Down Immediate Action, but Passes Long-term Approach to Ambulance Crisis. 2024: Portland,OR

20. Haas, E. and A. Plante, Multnomah County Commissioners Meieran, Vega Pederson Clash Over Ambulance Staffing Crisis. 2024: Portland, OR

21. Nelson, T., Deputy Board Clerk, Board of County Commissioners, Multnomah County, Oregon, Minutes of the Multnomah County Board of Commissioners, Thursday, June 6, 2024,. 2024: Portland, OR

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