News & Updates

Interesting…

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Has the fire service reached a tipping point? Readers weigh in.

The FireRescue1 community considers what is driving high stress and staffing challenges

January 02, 2024

https://www.firerescue1.com/staffing/has-the-fire-service-reached-its-tipping-point-readers-weigh-in

With the fire service facing a perfect storm of stressors, we once again asked the critical question, “What do firefighters want?” The short answer revealed through the more than 2,100 participants in the 2023 survey: stress relief and staffing.

The What Firefighters Want digital edition featured the flagship article, also lead by a question – “Are we at a fire service tipping point?” – by Dr. Reginald Freeman, who explained that while firefighters feel generally positive about the job, they report high stress, and many have considered leaving their organization. Freeman evaluates some of the possible reasons for this and concludes his analysis with this statement: “Servant leadership and transformational leadership emulation is not common throughout the fire service. We have plenty of people in positions of authority, but that certainly doesn’t automatically qualify them as leaders.”

Freeman’s article resonated with FireRescue1 readers, many of whom shared their thoughts on the fire service tipping point on Facebook.

Following is a snapshot of the top comment themes. Join the conversation.

Wanted: Strong leadership

“Real firefighters and true leaders rarely move past the company officer level. The guys who don’t understand the job at the rank and file and have poor leadership skills always seem find a way to promote up to administration.”

“Real leaders should make the commitment to a higher rank. Some seem to, but the majority don’t. … I can understand why guys that should promote, don’t promote. It’s comfortable where they’re at and you’re really taking a chance.”

“It’s a very specialized position. Too often we just hand the Chief’s position to someone because they are well liked. It takes more than just being liked at a company level to be the Chief. I also think, and would assume you would agree, each department has its own issues to address when it comes to finding a Chief.”

Not-wanted: EMS

“After 26 years of full-time fire service, I can definitely say EMS is the cancer. No one wants to say ‘no’ to the abusers of the system. It single handedly kills morale. People who call 100+ times a year with no problem are the real reason people no longer care. Fix this and fix the problem.”

“Get rid of EMS and keep it separated from firefighting and you will have more applicants for both.”

Political problems

“The disrespect we get from politicians on both ends of the spectrum is spirit crushing. As long as the boss keeps his job by keeping the politicians blissfully unaware of the FD, there is no impetus to improve the work conditions and preparedness of those of us on the line.”

“Politics seems to get in the way at every level.”

“I get frustrated a lot and more and more as I get older. However, this job has given me so much and yes at times it has taken things from me. However, it’s a job I still love and no chief or politicians will take that from me.”

The job has changed

“Used to be that a public pension and benefits were well worth it. Now the benefits have been reduced and the pension isn’t as great. Plus, EMS has become the biggest part of career fire departments’ call volume. Stress, overwork, pay not keeping up with inflation, all play a part. As far as volunteering, it is hard to get people to commit the time for free when they have bills to pay. I always ask, why is firefighting the one job that people expect to be done for free? Because some people want to be firefighters so bad that they will do it for free.”

“I would say it has less to do with the runs/station life and the ‘actual job’ and more to do with the crap we put up with from city and admin. In the 12 years I’ve been with my city, we have changed computer programs 3 times. And each time we are told the preplans and such will transfer. Each time it doesn’t then we have to do all that work again … and since it’s new software we can’t access the old stuff so we need to research everything again leading to more and more apathy towards getting good info. We’ve moved away from in person hands-on training to favor computer training. There is more office/desk work than actual ‘fun’ work. It’s not the same job it used to be, and I get why people retire because they don’t want to do it anymore.”

“The increasing call load. Population booms outpacing the resources of law enforcement, fire/EMS, and available hospitals. Declining interest from the newer generations to do the job resulting in staffing shortages. Forced overtime leading to divorces. Dealing with an increasingly hostile and unreasonable public. Politicians from either of the dominant two parties sliding public safety to the back burner.”

“Time is the first and worst when it comes to [volunteering] … When you look at how many hours you’re going to have to spend in a classroom right off the bat, you look at your work schedule, and this is where it ends for a number of them. … Someone who’s already limited on their time would probably be the last to make it from home when the pager goes off. Considering the days of the volunteering are coming to an end, it was very easy for the local governments to step in if they were not already, and demand changes be made. Since many fire companies around the country are community supported, it would have been a better thought to retain what we had at the time, versus making dramatic changes, and hoping everyone understands and rolls with them.”

Do you agree with these comments? Join the conversation.

Based on the publisher/author, this may be a touch ‘self-serving’, but certainly something EMS agency leaders, personnel and communities should continually research for enhanced clinical care and operations.

Many High-Performance/High-Value EMS agencies, such as MedStar, and other AIMHI member agencies, are using machine learning and big data analytics for applications such as temporal and geospatial resource deployment, clinical treatment advances, and EMS response plans based on presumptive emergency medical dispatch determinants that are done by well trained and quality assured call-taking personnel.

To highlight the emerging roles for AI in EMS, the NAEMT Board of Directors will be holding its January winter board meeting at the Arizona State University’s AI Center, learning about potential AI applications for EMS.

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The Role of Artificial Intelligence in Pre-hospital Care

December 26, 2023

https://anyuakmedia.com/the-role-of-artificial-intelligence-in-pre-hospital-care/#gsc.tab=0

Artificial Intelligence (AI) has been making waves in various industries, and now it is revolutionizing the field of emergency medicine. In particular, AI is playing a crucial role in pre-hospital care, transforming the way emergency medical services (EMS) respond to emergencies. With its ability to analyze vast amounts of data and make accurate predictions, AI is enhancing decision-making, improving patient outcomes, and ultimately saving lives.

One of the key applications of AI in pre-hospital care is in the field of dispatching. Traditionally, emergency calls are routed to dispatchers who gather information from the caller and determine the appropriate response. However, this process can be time-consuming and prone to human error. AI algorithms, on the other hand, can quickly analyze the caller’s information, identify the severity of the situation, and dispatch the appropriate resources accordingly. This not only saves valuable time but also ensures that the right level of care is provided from the moment the call is made.

Once EMS personnel are on the scene, AI continues to play a vital role. AI-powered triage systems can quickly assess a patient’s condition and prioritize treatment based on the severity of their injuries or illnesses. By analyzing vital signs, symptoms, and medical history, these systems can provide EMS personnel with real-time guidance on the best course of action. This not only helps in delivering prompt and appropriate care but also reduces the risk of errors or delays in treatment.

In addition to triage, AI is also being used to assist EMS personnel in making critical decisions during emergencies. For example, AI algorithms can analyze data from various sources, such as medical records, lab results, and imaging scans, to help diagnose conditions or predict complications. This can be particularly valuable in situations where time is of the essence, such as cardiac arrests or trauma cases. By providing EMS personnel with accurate and timely information, AI empowers them to make informed decisions that can significantly impact patient outcomes.

Furthermore, AI is enabling EMS personnel to better monitor patients during transport. AI-powered monitoring systems can continuously analyze vital signs, detect changes in condition, and alert EMS personnel to potential complications. This allows for early intervention and prevents adverse events during transit. Additionally, AI algorithms can also provide real-time feedback and guidance to EMS personnel, ensuring that they are delivering the most effective care throughout the journey.

The integration of AI in pre-hospital care is not without its challenges. Privacy and security concerns, as well as the need for extensive training and education, are some of the hurdles that need to be addressed. However, the potential benefits far outweigh the challenges. AI has the ability to enhance decision-making, improve efficiency, and ultimately save lives in pre-hospital care.

In conclusion, AI is transforming the field of emergency medicine, particularly in pre-hospital care. From dispatching to triage, decision-making, and patient monitoring, AI is revolutionizing the way EMS personnel respond to emergencies. By leveraging the power of AI, emergency medical services can provide faster, more accurate care, leading to improved patient outcomes. As technology continues to advance, the role of AI in pre-hospital care is only expected to grow, further revolutionizing emergency medicine and saving more lives.

An outstanding report from the Minnesota EMS Regulatory Board (EMSRB) relating to the economic condition of EMS agencies in Minnesota!

Highlights and excerpts can be downloaded here:

Summary - Highlights - Minnesota EMSRB EMS Economic Report - 2023.pdf

The full report can be downloaded here:

Financial Evaluation of Minnesota's Ground Ambulance Industry - 2023.pdf

Outstanding work by Dylan J Ferguson, the Executive Director of the MN EMSRB, and his team for compiling and publishing this report!

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Furthermore, the report underscores the harsh reality that ambulance services often fail to recover the actual costs of providing their services. With a minimum of 62% of billable responses failing to recoup their true expenses, EMS providers face a substantial fiscal gap. This shortfall translates to a financial loss ranging from $34.47 to $463.44 for every Medicare or Medicaid response, a situation that is economically unsustainable in the long term. Addressing this issue necessitates a multifaceted approach, including a comprehensive review of billing practices, potential reimbursement adjustments, and strategies to enhance the efficiency of operations without compromising the quality of care.

In light of these findings, it is evident that action is required to ensure the continued availability of high-quality emergency medical services to our communities. Stakeholders in the EMS sector, including government agencies, healthcare institutions, and advocacy groups, must come together to address these challenges.

Operational Cost Per Transport: Operational costs per transport have surged, with an increase ranging from 55% to 189% since 2010. This escalation in expenses signifies the financial challenges faced by ambulance services in providing efficient and accessible healthcare transportation.

Insurance Billables and Payments: Ambulance services reported $1.2 billion in insurance billables but received approximately $450 million in insurance payments during the reporting period [a 37.5% collection rate]. The discrepancy between billables and actual payments raises questions about reimbursement rates and financial viability of ambulance services throughout the state.

Financial Loss: Alarmingly, 72% of reporting ambulance services reported some level of financial loss when comparing operational expenses to insurance revenues. This highlights the financial vulnerability of EMS providers, especially in light of increasing costs.

Shannon did a great job with this report!  Another example of the crisis facing EMS across the U.S. 

Rural communities have the greatest challenge, but urban communities are facing similar challenges…

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Your Ambulance Is on the Way. ETA: 65 Minutes.

Rural patients can wait an hour or more for emergency responders from strained services

By Shannon Najmabadi

November 16, 2023

https://www.wsj.com/us-news/your-ambulance-is-on-the-way-eta-65-minutes-0431facd

MERRIMAN, Neb.—Call 911 in this northwest Nebraska town, and the ambulance responding will likely be coming from South Dakota.

If that crew isn’t available, the ambulance might drive from Valentine, Neb., 60 miles and a different time zone away. Or from Gordon, where the all-volunteer staff includes employees of a grocery store, bank, veterinary office and farmer’s co-op.

“You’re looking at an hour or longer for a response,” said Rose Chappell, the last emergency medical technician in Merriman, which had to shut down its ambulance service. 

This patchwork has become the norm in many parts of America, putting some people at greater risk of death or serious injury as rural residents are getting older and small hospitals are closing.

Buck Buckles, a rancher, said the Merriman ambulance service picked him up after he fell off a horse in 2015, at age 74, breaking a shoulder and seven ribs. 

“If I had still been laying there waiting for an ambulance to come from Valentine, 75 miles away, or Hyannis, 70 miles away, I might have been dead,” he said. 

At least 4.5 million people nationwide live in an ambulance desert, where they are farther than a 25-minute drive from an ambulance station, according to a 2023 study. In Nebraska, more than 80% of emergency medical providers are volunteers working in sparsely populated areas where there are too few calls to justify having full-time staff, according to a 2019 study.

“I think that the majority of the American people do not understand how different it is out there,” said Andy Gienapp, deputy executive director of the National Association of State EMS Officials.

Rural ambulance services have been strained by a largely unprofitable business model, the pressure of the pandemic and recent struggles to hire people willing to undertake extensive training and work a high-pressure job for free, emergency medical personnel say. 

Most state and local governments aren’t required to fund ambulance services the way they do law-enforcement offices.

In Gordon, a town 30 miles west of Merriman, Neb., volunteers say they regularly leave their jobs midday or wake up in the middle of the night to respond to 911 calls.  

More than 55 ambulance providers have closed since December 2021, according to a log of news reports compiled by the American Ambulance Association and the Academy of International Mobile Healthcare Integration.

As departments close their doors, there is no agency “required to step up and fill that gap,” said Micheal Dwyer, a volunteer firefighter and emergency medical technician with Arlington Fire and Rescue in Nebraska. 

Merriman’s ambulance service is the first in Nebraska to close due to lack of a workforce, said Allan Urlis, spokesman for the state’s Department of Health and Human Services. The state, which is conducting an assessment of emergency medical services statewide, has offered grants to replace rural ambulances and reimburses some education and training costs.

Ambulance services are funded by a mix of patient bills, donations, taxes and fees. In some places, emergency medical services are provided by cross-trained firefighters, private companies or hospital employees. 

Industry experts say patient bills alone can’t cover the cost of providing ambulance services in a rural area—where emergency medical officials might respond to 100 calls a year but still require hundreds of thousands of dollars to buy and fuel ambulances.

Medicare, a federal health insurance plan for seniors and some people with disabilities, and Medicaid, a joint state and federal program for those with low incomes, typically don’t reimburse the full amount charged for an ambulance ride, those experts say. Medicare typically doesn’t pay for an ambulance if the patient isn’t transported to a hospital.

“We don’t control the calls we get, and we don’t deny calls,” said Michael Christensen, chief executive officer of the hospital in Martin, S.D., 18 miles north of Merriman. Grandma might have a bruise after falling down the stairs, he said—a 911 call the ambulance likely wouldn’t be paid for if the woman is treated at the scene—or “Grandma might have something horribly wrong—she fell down, banged her head and has a closed head wound that will kill her in an hour.” 

The pressure on ambulance services comes as many are seeing increased demand. 

Christensen’s hospital owns an ambulance service that responds to 911 calls across 2,000 square miles, including parts of two Indian reservations, three economically distressed South Dakota counties and a swath of Nebraska. The ambulance’s nine volunteers—paid $2 an hour to be on call—now regularly treat people who call 911 for minor ailments.

“We get phone calls because people in our area don’t have cars,” said Judi Claussen, who works in the hospital’s radiology department and volunteers for the ambulance service with her husband, a city councilman, and her daughter, the hospital’s lab technician.

Merriman is surrounded by sand hills and ranches. Its population shrank from 128 residents in 2010 to 87 residents in 2020, according to the U.S. Census Bureau. The local school and a senior center have closed, the dance hall has a broken window, and a sign at the beauty salon on the town’s main street says it is open one day a week. 

Chappell said she joined the town’s ambulance service in the early 2000s, when it had a crew of about 10 people. Over time, some of the Merriman ambulance volunteers grew old. Others moved away. Younger residents didn’t sign up. The ambulance service had little community involvement and ineffective management, a 2017 assessment found. 

By 2017, the service was down to Chappell and one other emergency medical technician. He resigned. Chappell was uncomfortable with answering calls by herself. The ambulance went into storage. It hasn’t responded to 911 calls in more than five years.

Chappell and members of the Merriman ambulance board have written letters, placed radio ads and made calls soliciting volunteers. Some people said they would sign up—including two people over age 70—but none followed through with completing the 150 to 200 hours of required training. This year, the ambulance board agreed to disband. The board is trying to sell its ambulance.

Neighboring ambulance districts answer emergency calls in Merriman, but the distance and reality of having volunteer staff with separate day jobs can eat into crucial medical response time, local responders say.

“It might take an hour to get out to the patient and an hour back,” said Nancy Hicks-Arsenault, interim CEO of the hospital in Valentine, where the ambulance service has 28 volunteers and covers a county larger than the state of Connecticut. 

“That golden hour of treatment is already exhausted,” Hicks-Arsenault said. 

The current crisis stems in part from the industry’s decadeslong reliance on volunteers, whose free work subsidized the largest cost of running an ambulance service, said Gienapp, with the national emergency medical services association. 

Fewer people are volunteering now, in part because rural populations are shrinking and remaining residents are older; adults 65 and older are the age demographic most likely to need ambulance services, studies show.

With fewer volunteers shouldering the work, small ambulance crews can flame out from the stress of being on call around the clock or from seeing community members in medical distress. 

In Gordon, a town 30 miles west of Merriman, volunteers say they regularly leave their jobs midday or wake up in the middle of the night to respond to 911 calls. 

“You’re running every call and we’re seeing a lot of really, really bad things,” said Alyssa DeHart, who volunteers with her husband Nick. “And then, we’re the only ones that are doing this.”

“There’s no one coming to help us.”

Interesting, and transformative approach to an on-going struggle for many EMS systems.

You can view copies of the letter and the Buncombe County EMS and State of North Carolina Policy in the link.

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County to Mission: 'ER situation unsafe, unsustainable;' new ambulance wait time policy

By Mitchell Black

Asheville Citizen Times

November 13, 2023

https://www.citizen-times.com/story/news/local/2023/11/13/buncombe-may-change-mission-emergency-dept-patient-handoff-policy/71530048007/

ASHEVILLE – In the wake of increasing wait times for ambulance patients who are "parked" when arriving at the Mission Hospital Emergency Department while waiting for the hospital to accept them ― a patient and emergency services safety concern highlighted by the Citizen Times ― Buncombe County plans to implement a new handoff policy, according to a county letter to the hospital obtained by the newspaper.

The new policy allows county Emergency Medical Service workers to leave stable patients in the hospital staff’s care after the ambulance arrives, even if a bed is not ready for the patient.

County Manager Avril Pinder and Emergency Services Director Taylor Jones informed Mission Hospital Chief Operating Officer Wyatt Chocklett in a Nov. 3 letter that Buncombe would implement this policy by Dec. 15 unless the hospital makes substantial strides to fix the problem.

HCA Healthcare, a Nashville-based for-profit company, bought the Mission Health system in 2019 for $1.5 billion.

Wait times have grown significantly for Buncombe County ambulance patients arriving at the Mission Emergency Department in Asheville. Through the first three quarters of the year, 309 ambulance patients endured more than hourlong wait times at the Mission ED, according to data provided by Buncombe County EMS.

In 2018, four patients experienced more than hourlong wait times.

Mission Hospital spokesperson Nancy Lindell referred the Citizen Times to past statements regarding questions about the hospitals efforts to correct the long wait times. Lindell said in those statements that demand for emergency services is growing in WNC, that the hospital prioritizes patients based on acuity and pointed to Mission’s proposed freestanding emergency departments as a solution to relieving the burden on the emergency department.

In July the Citizen Times reported that hospital staff and local emergency service leaders pinned the lengthening wait times on an overtaxed emergency department and understaffed hospital patient care team, saying that the hospital does not have enough staff to quickly treat, admit and discharge patients.

Long wait times at the hospital has an immediate impact on the county’s emergency medical service response time, according to the letter.

The federal Centers for Medicaid and Medicare Services guidelines, in part say the "practice of 'parking' patients arriving via EMS, refusing to release EMS equipment or personnel, jeopardizes patient health and adversely impacts the ability of the EMS personnel to provide emergency response services to the rest of the community," the letter said. CMS guidance also notes that it is appropriate for paramedics tend to patients if hospital staff in the emergency department is overwhelmed.

“There is a direct correlation between the increase in BCEMS’s response times and the increasing handoff times at Mission,” Pinder said in the letter. “This is unfair to Buncombe’s community and puts unreasonable stress on BCEMS personnel who are already performing a stressful job. The current situation in the ER is unsafe and unsustainable.”

Buncombe County bills ambulance patients on a flat fee for the level of care provided and the distance the ambulance travels, which does not account for the time paramedics spend treating patients.

When paramedics spend time treating patients arriving at the emergency department, the amount the county charges the patient does not change. Pinder argued in the letter that this treatment “can be seen as Mission receiving a taxpayer subsidy.”

“If Buncombe is paying the EMS employees’ time and salary to pick up and transport patients, but instead they are providing care in the hospital, that is the subsidy,” she said in an email to the Citizen Times.

Lindell did not respond to a Nov. 9 Citizen Times question about Mission effectively receiving taxpayer support by press time.

Buncombe County’s policy will only apply to stable patients. The amount of time paramedics wait with patients depends on the number of EMS vehicles in service:

• If more than six vehicles are in service, and there are no upcoming needs, paramedics will wait 45 minutes.
• When fewer than six vehicles are in service and there are no upcoming needs, paramedics will wait with patients for 30 minutes.
• If there is one vehicle in service or there are “high upcoming needs” with fewer than three vehicles available, or there is a mass casualty event, paramedics will immediately hand off patients and return to service.

The policy also lays out the county’s process for communicating the handoff to the Emergency Department staff and finding a location for the patient before EMS staff departs.

Buncombe County’s new policy will be the second recent major change a local emergency service department has made to address growing wait times at Mission Hospital. McDowell County announced that it will suspend noncritical patient transfers from McDowell Hospital in Marion, to Mission. In a letter informing Chocklett of the change, McDowell emergency services noted several critical patients who waited extended periods once they arrived at the hospital.

The impending changes come on the heels of a letter the North Carolina Attorney General’s Office sent to Dogwood Health Trust, delivering notice that HCA violated the commitments it made as part of the 2019 agreement to purchase the Mission Health system. This letter specifically notes that HCA failed to comply with its emergency service-related commitments.

Dogwood, the nonprofit formed to receive the proceeds of the sale, has 40 days to work with HCA to fix the problems, otherwise the NCAG’s office can bring a lawsuit.

The North Carolina Department of Health and Human Services recently awarded Mission a Certificate of Need for a freestanding emergency department in West Asheville, which AdventHealth appealed.

This is a very well-done radio news report on surprise payments. 

Gotta love non-profit radio’s in-depth reporting, AND use of cool audio to convey important information in an understandable and immersive way.

Strongly recommend you listen to the audio report – very well done.

And tip of the hat to Pete Lawrence and Butch Oberhoff for their contributions to the report!

And, thank you to West Health (a strong supporter EMS transformation) on supporting this report…

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Can the U.S. Put an End to Surprise Ambulance Bills?

NOVEMBER 9, 2023

https://tradeoffs.org/2023/11/09/surprise-ambulance-bills/

Congress banned most surprise medical bills back in 2020, with one major exception: ambulance rides. Most people agree that patients should be shielded from these unexpected charges. But who should pick up the tab instead?

This week, as state and federal policymakers grapple with that question, we delve into why finding a fair solution is harder than you’d think.

Listen to the full episode or read the transcript below, and check out our reporting partner STAT’s story for more information. 

Dan Gorenstein: Every year in America, ambulances make more than 20 million runs to the hospital — cyclists hit by cars, seniors paralyzed by strokes, kids shot by guns.

[Sfx: Ambulance sirens]

These rides give people in some of their worst moments their best chance at staying alive. But they can also leave a lotta people feeling blindsided.

Precious Mae Clark: I thought I was prepared. I thought I covered my bases. But this ambulance bill, it rocked my world.

DG: For patients with private insurance, as many as 1 out of every 4 ambulance rides could end up in a surprise charge. But cities and counties say they rely on these fees to fund life-saving emergency services.

Today, the price patients pay for these unexpected bills — and a federal committee’s fraught plan to end them.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

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DG: Precious Mae Clark likes to be prepared.

PC: You know, I’m an overthinker. I’m a worrier.

DG: She opens every bill as soon as it arrives. [She] keeps a close eye on her credit score. And her hope is all this worrying will pay off one day when she and her husband can buy a home.

PC: I don’t want a fantasy house. I’m not a fan of those. I just want a house that we can call our own and my daughter and my dog can run in the backyard. So that’s how I imagine our life.   

DG: Precious, who’s employed by a lending company in Columbus, Ohio, has worked hard for that dream since arriving in the U.S. from the Philippines in 2020.

Last year, though, she saw how shaky life here can be. A medical scare walloped her with a bill for nearly $5,000. The solution? More protection, more preparation.

PC: I learned my lesson. I said this year, I’m going to get a lower deductible insurance. 

DG: She even bought extra coverage — a special policy that covers hospital costs just in case. And it turned out in January of 2023, she needed it. 

[Sfx: Hospital sounds]

PC: I was just trying to open my eyes… 

DG: Doctors had just told Precious that her lung had collapsed. A tube ran to her ribs. Someone told her she needed to be transferred from this emergency room to a full hospital.

But her lung, the tube, the transfer [were] all details. Precious focused on one thing.

PC: I don’t care what you do to me, but, you know, just make me live. Make me live.

DG: Then doctors put her in an ambulance…

[Sfx: Ambulance sounds]

DG: 30 miles south to a hospital in Grove City, Ohio.

[Sfx: Ambulance sounds]

DG: In a strange room the next morning, [with] monitors beeping [and her] mind swirling, Precious was glad she had prepared herself, financially, for this medical crisis.  

PC: I was super confident that I have, you know, good insurance. So I was calculating my copay, and I’m good. So, no worries on that. 

DG: Yep, no worries — until a shock arrived in her inbox six months later.

PC: I thought it was just like those $20 copays, but when I opened it, it’s like, I panicked literally seeing it. I panicked, like, what is this?

DG: A bill for $7,370.45 — nearly twice what she and her husband make each month.

Precious Mae freaked out.

PC: Where am I going to get $7, 000? Maybe this is an error. Why is this so high? Was my insurance used by someone else? Why are you sending me another bill? $7? $7? $7,000? It kind of, like, clogged my brain.

DG: Research shows that when a patient calls 911 — or is transferred from one hospital to another, like Precious was that cold January night — more than half the time those rides are out of network. The insurance company explained to Precious [that] the ambulance she rode in was not covered.

PC: Does that even make sense that your insurance did not cover the ambulance that saved your life because it’s not “in network”? Like, does that even make sense?

DG: Like most people in crisis, Precious didn’t have the time or the power to pick her ambulance, like you might with a doctor or a dentist.

PC: After the lady explained to me on the phone, I was talking to her and I was crying. I was just super angry with the system.

It’s just so frustrating. What frustrates me so much is that I’m paying extra for better insurance. I’m paying extra every month on my paycheck, just so I can get the peace of mind. And then suddenly, that peace of mind was just, like, thrown out in the trash.

DG: All that extra time, money and effort spent trying to protect her family from a financial disaster for what?

PC: It sucks that you’re trying to work your ass off, be a good citizen; and yet, you get something surprising like this and you’re not prepared for it.

DG: Precious could imagine debt collectors calling, blowing through her savings.

PC: To be honest, when I saw that bill, I lost hope living here. I thought, “You’re not going to go anywhere here, because something’s going to pull you back.”

DG: She was grateful for the care that had kept her alive. And because she was alive, she refused to let a bill sink her and her family.

She called everyone she could — the hospital, the insurer, the ambulance company — [and] implored them to see her side of the story. She had no way of avoiding this ride. They had to reconsider. 

PC: It was a dead end with your insurance. It was a dead end with the ambulance. Like, that’s it. I just felt the entire system is bullshit at that point.

DG: Patients like Precious get tagged with up to $130 million a year in unexpected ambulance fees.

Congress had a golden opportunity back in 2020 to end all this when they banned nearly every other kind of surprise medical bill, but they punted.

The reason has a lot to do with who is sending these bills. Sure, some come from for profit players, but most come from places like the fire station down the street.

So, that’s where we dispatched senior producer Leslie Walker. Leslie’s mission: Follow the money; better understand who these surprise bills are coming from; and what all this money goes to.

[Sfx: Fire station chatter]

Leslie Walker: I get to Fire Station 2 with the SoCal sun beating down on me and a few palm trees towering overhead. Inside the firehouse kitchen, with close cropped hair and a crisp navy blue uniform, is Pete Lawrence.

Pete Lawrence: I’m the Deputy Fire Chief for Oceanside Fire. I’ve been here 34.5 years and I run the department’s finance, administration, billing and emergency management sections.

LW: The ambulance company that stuck Precious Mae Clark with her surprise bill is privately owned, but the majority of all emergency rides in the U.S. are delivered by government-run outfits like Pete’s.

PL: We run eight engine companies, one ladder truck, seven ambulances and they together run about 24,000 calls a year.

LW: About 80% of those calls are medical. Most of them [are] garden variety emergencies.

Firefighter-Paramedic Mike Presti: A mild-status trauma…

LW: The kinds of calls I saw as I rode around Oceanside with a couple of Pete’s guys. Our first stop [was] an older woman who’d taken a spill on some concrete steps.

Presti: You hit your head pretty good…

LW: Next, a 79-year old struggling to stand.

Presti: How long were you on the floor?

LW: To end our run, Mike Presti, the firefighter-paramedic relayed the call.

Presti: A 16-year-old not able to say words, not knowing what’s going on.

LW: Over about five hours, I saw Mike start a few IVs, attach a neck brace [and] run some basic medical exams, but some other crews out that day were responding to some really serious stuff. 

Ambulance Dispatch: Solano Beach. Traffic Collision. Engine 237. Engine 238. Medic 237… 

LW: Calls for car crashes, a suicide attempt, a person on meth in crisis, a pair of kids who had taken a parent’s pills.

Ambulance Dispatch: San Marcos. Traffic collision. Engine 143 and RA 144 at 2469 through 2699 North Twin Oaks Valley Road…

LW: Chief Pete says teams have to be ready for the severe calls, plus wildfires, mass shootings [and] pandemics. That takes a lot of people power and a whole bunch of medical supplies.

PL: Essentially, we are an emergency room on wheels. 

LW: He opens up the side door to Rescue Ambulance 212.

PL: This is a paramedic ambulance. Its replacement cost nowadays is about $450,000.

LW: And is that just the equipment when you say that? 

PL: No, that’s just the vehicle!

LW: The equipment, Pete adds, is another $100,000 to $130,000. There’s the usual stuff: a gurney, a stair chair, bandages, splints…

PL: We carry back boards. We’ve got radios. Each radio is about $7,000.

LW: Then there’s the big ticket items. The drug box. 

PL: And all of the medications inside that drug box are about $30,000.

LW: There’s a $40,000 heart monitor that can pace, can defibrillate and can send all these readings to the hospital from the road. 

And the crown jewel: a machine that looks like a sleek white carry-on suitcase.

PL: It performs absolutely perfect CPR. You push the button, and it goes. It doesn’t get tired. It doesn’t take a break. It saves lives every year. 

LW: Pete’s voice even breaks a little talking about the miracles he’s seen this machine work.

PL: It’s just — you’ve got individuals who are clinically dead and we turn them over to the hospital and the hospital has got a fighting chance. Other than delivering somebody’s child in the back of your ambulance, having somebody show back up at your station and thank you is about as emotional as you’re going to get. And it just is an amazing experience.

LW: In the earliest days of emergency transport, undertakers volunteered their off duty hearses to shuttle neighbors to the hospital. Over time, the public’s bar has been raised just a bit, says Dia Gainor with the National Association of State EMS Officials.

Dia Gainor: So if you were to randomly, you know, survey citizens and say, “If your husband was having a huge heart attack right now and you called 911, what would you expect?” People are not going to say, “Oh, I expect a pickup truck and a guy with a box of Band Aids,” right? What’s the public’s expectation? A full-size ambulance, a well equipped, well trained crew who can save their husband’s life. Period.

LW: And arrive within 12 minutes. Today, cities and states often enshrine our ambulance expectations into law. 

In Oceanside, ambulances have to be on scene in 12 minutes 90% of the time. Providing this high-quality, potentially life-saving service means having a certain level of redundancy, inefficiency — having more expertise and more equipment than what many calls actually need. 

PL: The cost of readiness for public and private EMS providers is a huge cost for us, whether they go on a broken finger or on a cardiac arrest [call]. You don’t have the ability to say, “Leave us a message and we’ll call you back as soon as the unit’s available.”

LW: Pete says when you add up all their costs, the tab runs about $1,200 per ride.

PL: Our average reimbursement is about $610 to $620.

LW: That rate, says Pete, puts his team in a tough spot. Hit up patients — the people they serve — for the difference, or take taxpayer dollars — money that could instead be spent on libraries, homeless services, parks. 

But to the companies forking over 50% of that bill, they’ve paid their fair share.

James Gelfand: It’s one thing to get into a helicopter with a neurosurgeon and a team of nurses and a host of medications and machines keeping you alive, and it’s another to get into the back of essentially a van with an EMT and drive for five minutes to get to a hospital. But somehow both of these bills are going to be in the thousands of dollars. It doesn’t make sense.

LW: James Gelfand represents large employers who pay some of these ambulance bills. He’s president and CEO of the ERISA Industry Committee — sometimes called ERIC.

James says for him, the math here just doesn’t add up. A paper in Health Affairs shows for-profit ambulance bills tend to run much higher than publicly run ones, like Pete’s. He also points to instances when a full fire truck shows up for someone with a sprained ankle.

Gelfand: And the cost of paying for an Uber for those individuals might be $8 to $10. But I’m sure that those ambulances are billing the city thousands and thousands of dollars for every ride.

LW: Underlying these guys’ fight over numbers is a fundamental question. Who should shoulder the cost of this, again, potentially life-saving service?

Gelfand: I think it’s very easy to say that a patient shouldn’t be caught in the middle or be charged a bill, but it’s a lot more challenging to say how much should an ambulance be able to charge? And [for] the insurance company or the employer that’s going to have to pay, how much should they have to pay?

DG: Pete Lawrence agrees those are the essential questions. The federal government even charged him and a committee of 16 other advocates and experts with trying to answer them.

That committee rolls up its sleeves and Precious gets some good news after the break.

DG: Pretty much everyone in Congress agrees patients like Precious Mae Clark should be shielded from out of network ambulance charges. And pretty much everyone in Congress agrees they want to avoid de-funding the Chief Petes in their own districts.

Dia Gainor of the National Association of State EMS Officials says the hard question for lawmakers is deciding who should pick the costs up instead.

Gainor: There’s no silver bullet here. If there was, we would have found it in the holster.

DG: Fourteen states have taken matters into their own hands, passing at least some protections for patients. And experts say two approaches are likely to get the most interest from Washington.

Tara Bannow: Let local governments name their price and force insurers to pay it.

Bob Herman: Just go with some percent of what Medicare pays and call it a day.

DG: Those are our reporting partners for this story: Bob Herman and Tara Bannow from STAT, the health news outlet. We asked them to give us the scoop on this pair of state fixes for surprise ambulance fees.

First up: Tara Bannow, who looked at the solution known as local rate setting. Tara, what’s the basic idea here?

TB: So this approach does two things. First, it bans ambulance providers from billing patients extra for out-of-network rides, like what happened to Precious. Second, it makes the patient’s insurer pay more instead.

Exactly what the insurer owes is based on a rate that’s set by either a city, a county or another local authority. These rates actually exist in a lot of places already. The purpose of these laws is to force health insurers to actually honor them.

DG: And how many states have passed this type of law, Tara?

TB: Four states so far, and they’re all very new laws. Arkansas and Louisiana’s laws took effect in August. And Texas and California have similar ones and they’re taking effect in January of 2024.

DG: So obviously it’s too soon to know how these laws are affecting the bottom lines of insurers, fire stations or for-profit ambulance companies. But what, at least in theory, Tara, is the biggest upside of this approach — aside, of course, from protecting patients? 

TB: I thought Butch Oberhoff, president of the Texas EMS Alliance, put the case pretty clearly.

Oberhoff: Local elected officials are the ones who know best about the true cost of providing EMS in their own communities.

TB: And, you know Dan, it’s also hard to ignore that most of the states taking this approach — Louisiana, Arkansas, Texas — are politically conservative places where raising taxes is very unpopular. So forcing insurers to pay these local rates is an appealing way to make sure that ambulance providers are made whole; patients don’t get surprises; [and] taxpayers don’t get stuck with the tab. 

DG: And I’ve got to imagine this approach makes insurers and employers — the ones paying these rates — sort of nervous, right? Like how much can they trust these home-cooked numbers?

TB: Yeah, critics argue that if ambulances can name any price, they lose any incentive to save money, [and] local governments could inflate rates — use insurers as a kind of cash cow to cover other costs. 

DG: And just to connect the dots here, Tara, that could ultimately hurt patients, right? If insurers’ ambulance costs go way up, they could turn around and raise premiums on patients like Precious. 

TB: In theory yes, though for some perspective here: Sources told us ambulance costs are a very small sliver of insurers’ overall costs. So, it’s unlikely that they radically change our premiums.

Backers of this approach, like Butch in Texas, add that local rate setting is public and transparent. Finally, at least one of these laws does include a cap on how fast the local rates can be hiked.

DG: Very good. Thanks so much, Tara. Really appreciate it. 

TB: You’re welcome.

DG: Bob, your turn. You got the skinny on another approach states have taken to this tricky question.

Bob Herman: That’s right, Dan. So this other fix has been adopted by two states: Colorado and Maine. Rather than letting local governments name their price, these states did something different. They use what Medicare pays for ambulance services kind of as a benchmark, and then they go up from there. So in Colorado, private insurers agreed to pay 325% of Medicare’s rate — and in Maine, they settled on 180%.

DG: And so this approach, Bob, seems a bit more like a compromise. Like, the local ambulance providers — the Chief Petes — won’t get every dollar they want, but they’ll get closer to what they think is the full cost of the care. 

BH: Yeah, I mean, how fair of a deal you think it is really depends on what you think of the rates Medicare pays. Now as you might expect, insurers like the lower government rate. But ambulance providers say Medicare pays way too little.

So, in Colorado, ambulances run by cities, towns and counties balked. They told lawmakers, [who offered] 325% of Medicare, they weren’t going to participate.

DG: Wait. Three times the government’s rate and they still turned it down?

BH: Yeah, exactly. So patients who happen to take one of these publicly run ambulances in Colorado can still get hit with a hefty bill. 

But, Dan, this whole Medicare benchmarking approach might be doomed at the federal level. I talked to Zach Gaumer, a consultant who used to advise Congress on Medicare policy.

Zach’s actually done the math. He mapped out how the current rates that private insurers pay ambulances compare to what Medicare pays, and Dan, it was all over the place.

Gaumer: The variation in the payments that I see suggests that almost whatever level they pick, there’s going to be significant winners or losers.

BH: It’s going to be really hard for any member of Congress to sign off on a plan that slashes their ambulance services, obviously.

DG: Thanks, Bob.

BH: You’re welcome, Dan.

DG: Just last week, we got a glimpse at how a debate on the Hill might go.

GAPB Committee Meeting: There’s a lot of blood, sweat and tears that have gone into this. So thank you so much for the significant time commitment…

DG: Pete Lawrence and the 16 other members of the federal Advisory Committee on Ground Ambulance and Patient Billing voted on a plan that will be delivered to Congress early next year.

GAPB Committee Meeting: Alright, Tara, if you’ll take the vote. Regina Crawford? Yes. Rhonda Holden? Yes. Patricia Kelmar? Yes.

DG: Almost every member agreed to end the surprises and instead charge privately insured patients a predictable max of $100 per out-of-network ambulance ride.

But when it came to deciding what insurers and employers should pay for those rides, things, predictably, got sticky.

Montage of GAPB Committee Meeting: There needs to be a role of the local community // That we wouldn’t have ambulance services, that’s nobody’s intention here. // I think that is imperative. // I also just think this is a huge bureaucratic boondoggle. // And I just simple can’t support it.

DG: In the end, a majority voted to force insurers to pay whatever rate state lawmakers or local officials set — with no cap on those rates. The other option — Congress using some multiple of Medicare — got just three votes.

To end things, I want to bring back all three of our reporters for this story — Leslie, Bob and Tara — for a couple last questions.

Bob, let’s start with you. 

One thing I’ve been wondering is why wouldn’t lawmakers just go with the solution Congress already came up with in 2020 when they banned other surprise bills: Force these ambulance providers and insurers to negotiate [and] reach a fair rate amongst themselves? 

Why reinvent the wheel here?

BH: Well the reality, Dan, is that negotiation — or arbitration process as it’s called — it’s been a disaster. The federal government released a report that said in the last quarter of 2022, there’s been more than 100,000 disputes alone. Now imagine doing that for millions and millions of ambulance rides a year. That just doesn’t seem tenable to most experts out there.

DG: Fair enough. But I guess, the alternative here of lawmakers, whether in Washington or on the local level, just setting rates on their own seems like a tough sell too.

Tara, what’s the future hold here if Washington continues to kick this can down the road?

TB: It’s impossible to predict exactly how many more states would pass their own laws, but the truth is, Dan, no matter how many states pass these surprise bill bans a huge chunk of patients in those states will still be exposed.

Most people who get insurance through work in the U.S. — about 130 million of us — get it from employers who manage their own insurance plans. These plans — so-called ERISA plans — are exempt from a lot of state regulations including these surprise bill bans. 

And Matt Zavadsky with the National Association of EMTs told me those conversations could get pretty thorny. He pointed me to Charlotte, North Carolina where, earlier this year, the county did actually decide to lower their ambulance expectations and save taxpayer money. 911 callers with less urgent needs can now wait up to 60 [or] even 90 minutes for an ambulance.

Zavadsky: The reality is that local communities have a very difficult decision to make: what they want the service level to be and how much they’re willing to fund. And that is the intersection of what your wallet can bear and your stomach can withstand.

DG: If Congress punts again on a path forward, public servants like Pete and patients like Precious will still be left in the lurch.

For Pete, California’s new law forcing insurers to pay local rates for ambulance rides applies to just a small fraction of bills. And, a chunk of public money that Pete’s team relies on from a local sales tax goes before voters in 2024. If that vote fails, Pete’s preparing to cut at least three ambulances from his fleet.

As for patients, without federal protection, many will continue to rely on what’s become a sadly predictable playbook in American health care: Pass a hat around on GoFundMe, beg a journalist to shame your insurer or spend hours on elaborate appeals processes.

Precious opted for the latter two. With help from STAT’s Bob Herman and a whole lot of her own letter writing, Precious heard back from her insurer on September 23.

PC: I was like, was there an error again? I will have to owe more? So I opened it with so much, so much fear and I saw it’s zero dollars. 

DG: Her insurer had decided to pay the entire bill — chalked the whole situation up to a “manual processing error.”  

I’m Dan Gorenstein. This is Tradeoffs.

Tradeoffs’ coverage of health care costs is supported, in part, by Arnold Ventures and West Health.

A well-researched news report. 

It’s interesting that the EMS levies in IA cannot be used for salaries, only training, equipment and supplies. States looking at essential service designation may want to assure that salaries can be part of the funding eligibility.

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‘Broken system’: Iowa’s rural ambulance services strained

In some parts of Iowa, 911 callers can’t be assured an ambulance will arrive

Liam Hala with Emily Andersen

Nov. 5, 2023

https://www.thegazette.com/health-care-medicine/broken-system-iowas-rural-ambulance-services-strained/

Radu Denghel always had been interested in medicine, but when it came time to decide what to study in college, he picked engineering — which also interested him but would require less time in school.

While going to engineering school in Romania, where he is from, Denghel also attended some classes at the local medical school and volunteered at the local emergency room.

Now, more than 20 years later, Denghel is in Iowa and still working in both fields — computer engineering in a full-time job with Collins Aerospace in Cedar Rapids, and medicine as a volunteer emergency medical technician for the Olin Ambulance service.

“I got to a point where my work pays my bills, so I don’t have to look for additional income and spend my time that way. And I really do believe that time is much better spent serving the community instead of just watching TV or whatever,” Denghel said.

But volunteer EMTs like Denghel are dwindling across the state, where emergency medical services are not considered an essential service statewide, meaning the Iowa Legislature does not regulate the service or provide funding for it. Two years ago, lawmakers passed a bill, Senate File 615, allowing voters in counties to declare EMS an essential service within their county and agree to pay taxes to support it.

But the availability of ambulances still is inconsistent across the state — especially in rural areas — and providers say more needs to be done to support a waning EMS force.

Even when EMS workers are paid and not serving as volunteers, ambulance providers struggle to maintain services due to high turnover, likely a result of low wages and increasing burnout. Pay for paramedics and EMTs in Iowa falls short of the state’s average wage of $25.73, with their mean wages falling at $23.31 and $17.74 respectively, according to the U.S. Department of Labor.

Low wages, combined with an average cost of more than $12,000 to obtain a paramedic’s license, mean filling the physically demanding job is increasingly difficult despite a growing need. A 2022 survey by the American Ambulance Association found that, nationwide, paramedic and emergency medical technician turnover can range from 25 to 45 percent annually — resulting in 100 percent turnover every four years or less.

Stresses on EMS providers

Emergency medicine can be physically taxing — carrying injured patients down tight stairways or out of the woods, for example EMS providers face some of the highest rates of on-the-job injuries. In 2020, almost 17,000 EMS providers in the United States were treated in the emergency room for injuries sustained on the job, according to the national Centers for Disease Control and Prevention. Many of the sprains and strains seen in the emergency department — 56 percent — were from overexertion, typically from carrying patients much larger than the provider.

Mark McCullough, legislative chair for the Iowa EMS Association, said technologies like stair-chairs and automatic gurneys help reduce injuries, but the equipment is expensive and some services — especially those relying on volunteers — don’t have them.

He also pointed to the high rates of burnout and suicide in health care workers as reasons many providers are leaving the field or moving to urban services that pay more.

Volunteer services struggle more than paid services to keep and retain providers, McCullough said. This is due to the massive time and financial commitment volunteer services require.

While Denghel was studying to get his EMT certification earlier this year, for example, he said he was working about 60 hours per week at his job and attending about eight hours per week of EMT training. Now he often has to plan his schedule around the availability of the other volunteers, so someone is always reachable in an emergency.

Kevin Stoolman, fire chief of Eastern Iowa’s West Branch, said rising costs leave many volunteer services like West Branch Fire stretched thin. The department provides fire and emergency medical services the town of 2,500, providing lifesaving care until a transport team from Tipton, West Liberty or sometimes Davenport arrives to take the patient to a hospital.

“Our goal is to have them packaged up and ready to go by the time the ambulance gets there,” Stoolman said.

But Stoolman said a rise in the number of calls the department has to answer is stressing the team and diverting money traditionally budgeted for fire protection and fire fighting to emergency medical services instead.

Minutes can matter

According to data from the Iowa Department of Health and Human Services, 75 percent of Iowa’s EMS services are entirely volunteer, though those volunteers respond to only about 10 percent of EMS calls in the state.

Paid EMS services handle most calls in Iowa, but not all areas have enough paid emergency transport staff to cover the need, causing them to rely on other ambulance services to help pick up the slack. This can lead to longer wait times for care.

Katrina Altenhofen, the interim director of the Washington County Ambulance Service, said Iowa lacks a standard of operation for ambulance services and the ongoing workforce shortage strains an already stressed EMS network.

When a lack of staff causes a service to decrease the number of ambulances it runs, other nearby services may be required to pick up calls outside their normal coverage area — resulting in longer response times in both areas, Altenhofen said.

“You have communities within the state of Iowa right now that don't even have ambulance services and don't have a hospital,” Altenhofen said. “So they are at the mercy of whoever is that next closest entity to be able to come down and help.”

Cedar County Sheriff Warren Wethington said ambulances in Cedar County can take between 15 and 45 minutes to respond to an emergency call, depending on what else is going on and where in the county the call comes from.

“Just last week, we had the Clarence ambulance out of service. Tipton has two ambulances and they went to take somebody to Iowa City and somebody to Cedar Rapids, and there was another call … and there wasn’t anybody to cover it. We had to wait until the crew came back from Cedar Rapids,” Wethington said.

All the ambulance services in Cedar County currently are volunteer, but Wethington has been working with other county officials to create an EMS referendum that will be on the ballot Tuesday. If passed, the referendum would allow the county to implement an additional property tax of 75 cents per $1,000 of taxable value. The tax would be used to create two paid ambulance services and possibly an additional volunteer service.

Wethington said some people have expressed concerns about the already existing ambulance services losing out on revenue they use for upkeep of equipment and other necessary expenses. But he stressed the new ambulances would not be meant to replace the volunteer services, but provide backup.

“I want to make it very clear that we want a partnership. We don’t want to take anything away from anybody. This is purely a backup for when they’re out of service, don’t have a crew, or are out on another call,” he said.

If the referendum is approved, Wethington said it could take up to two years before the new ambulances are fully operational.

Few counties have adopted EMS tax

Only a handful of Iowa counties have voted to make EMS an essential service and levied taxes to support it — leaving much of the state hanging in the balance.

Jones County is one of the five counties where voters approved a levy in November 2022. Brenda Leonard, the Jones County emergency management coordinator, said the county’s two full-time ambulances and multiple volunteer ambulances all have been understaffed and overly busy recently. She said many of the volunteers hold fundraisers to pay for equipment and training, and she’s hoping the new levy will mean paramedics no longer have to spend as much of their time fundraising.

“I think it has brought to light in our county that it was not an essential service. When you called 911, you were not necessarily going to get an ambulance,” Leonard said.

Sheila Frink, services director of the Anamosa Area Ambulance Service — the largest service in Jones County — said that Anamosa’s service is planning to use the money they will receive from a levy approved there to buy a new ambulance.

Anamosa’s ambulance staff are not volunteer, but the tax levy cannot be used for salaries. It can go only toward training, equipment and other expenses.

Washington County has not passed a tax levy for ambulance services, but the county has been fully funding emergency medical services since 2020 when supervisors used general county funds to purchase several ambulances and the building they were kept in from a private owner, according to interim director Altenhofen.

The county previously had subsidized the ambulance service in varying amounts each year, but took over completely when a contract with the private ambulance service ended. Since buying the ambulances, the funding has come from the county general fund and also the revenue brought in from the ambulance service, Altenhofen said.

The county also developed a Washington County EMS Council in 2020 that is working to put a tax levy for the ambulance service on the ballot in coming years.

“The Board of Supervisors recognized the need to be able to offer the citizens of the county emergency care. Waiting on an ambulance to come from Iowa City, Mount Pleasant, Marengo or Fairfield just was not a viable option,” Altenhofen said.

Since EMS still is not considered an essential service statewide, there is no obligation for ambulance services to take calls from other areas. In areas where EMS is not declared an essential service, there is no guarantee an ambulance will come at all when a patient calls 911. Many counties that rely on volunteer services don’t have a hospital, and many don’t have the tax base to help support the service, Frink said.

“It's a broken system,” Frink said.

How Little Placentia Broke a Fire Powerhouse’s Back

The results of this ‘dangerous’ experiment are in, and may be the old guard’s worst nightmare

By Teri Sforza

October 30, 2023

https://www.ocregister.com/2023/10/29/how-little-placentia-broke-a-fire-powerhouses-back/

Burly men packed the room, arms folded across their barrel chests. There wasn’t enough space for them all. Hundreds spilled into overflow rooms.

Dangerous. Destined to fail. Deceitful. Horrific mistake. 

One after another, firefighters and their union reps paraded to the microphone, trying to scare the bejeezus out of the mild-mannered councilfolk of little Placentia.

Risky gamble with people’s lives. Half-baked. Untested. Extreme.

It was 2019 and the wee city was contemplating the unthinkable — being the first to pull out of the regional (and very expensive!) Orange County Fire Authority (with its state-of-the-art water-dropping helicopters and bulldozers and hazmat equipment and swift water boats) to form its own “Fire and Life Safety Department.”

But it wasn’t just that. Placentia would do the even more unthinkable: Cleave firefighting duties from emergency medical duties.

No more (very expensive!) firefighters who are also paramedics at every call. No more 25-ton fire trucks arriving beside ambulances for routine medical mishaps. No more fire trucks and their (constant-staffing as per union contract) four-man crews accompanying those ambulances to the hospital and waiting (“wall time”) until the patient is taken by the E.R. before returning to service.

In Placentia’s proposed revolutionary setup (which is really only revolutionary in Orange and Los Angeles counties),

firefighters would do the firefighting and a private ambulance company would do the emergency medical/paramedic/lifesaving.

To the old guard in that room that night, this was Armageddon. The crack that could bring down the entire dam. It had to be stopped.

“A Placentia Police Department officer, God forbid, gets shot on these streets — I tell you right now they’ll be the first ones, as they’re bleeding out, wishing OCFA was en route, not a new fire department with volunteers,” Frank Lima of the International Association of Fire Fighters told the city council. “This dangerous decision is going to put somebody standing in front of a church at a funeral and you will own it. This vote’s going to follow you and we’ll make sure of that.”

And so it went. For hours. “Your consultants are selling you snake oil. You can’t get more with less. Your consultants — I’m going to tell you right to your face,” snarled Brian Rice, president of California Professional Firefighters, searching the audience for them. “If one member, whether they’re OCFA or one of these volunteers, gets injured, I’m going to come back and I’m going to sue your ass for everything you’ve got.”

We recall thinking that Placentia was, indeed, a bit crazy at the time. Providing services regionally is, at least theoretically, the more efficient way to go.

But these are fire services we’re talking about. Unions and management have agreed to staff up to handle extreme scenarios, despite their rarity, resulting in some crazy costs.

To wit: A Los Angeles city firefighter made more than $500,000 in overtime alone last year. An Alameda County firefighter made more than $400,000 in overtime alone. An Orange County Fire Authority firefighter made more than $290,000 in overtime alone. Surely, there has to be a better way.

Understand that little Placentia – population of approximately 52,000 – has teetered on the brink of bankruptcy. Its OCFA bill jumped a stunning 47% over a decade, for zero extra personnel or services. Its general fund budget increased only 12% over that time, and its police department budget was sliced 9% to help make way for the increased costs.

Craig Green was a city councilmember that fateful night. He gazed out the giant picture windows of the trendy Golden State Coffee Roasters in the heart of Old Town and grinned. “No dead bodies in the streets,” he said.

Four years later, the results of Placentia’s “half-baked,” “dangerous,” “reckless” experiment are in. And they may be the old guard’s worst nightmare.

Costly and outdated

City Administrator Damien Arrula was the rudder that kept the ship steady through stormy waters. Young, energetic, plain-spoken and well-versed in economic development and management analytics, he fought back at the fear-mongering and intimidation. He laid out painstakingly detailed, data-driven analyses of the city’s actual emergency needs and how they could be met with improved safety for less money.

”‘Unproven,’ ‘untested,’ ‘half-baked’ — these claims are false, absolutely false,” Arrula told the city councilmembers.

In fact, 56 out of California’s 58 counties already provide 911 advanced life support with private paramedic services providers. That includes nearby Riverside, San Bernardino, Ventura and San Diego counties.

“This is not only the primary model in California, but throughout most of the U.S.,” he said. “Only two counties in California do not currently use private 911 ALS paramedic services – Orange and Los Angeles.”

The city’s consultants did an enlightening “workload analysis” examining OCFA data. They found that:

• Placentia averaged 7.1 emergency medical calls per day, and 2 calls for other emergencies, for a total of 9.1 calls.
• That means nearly 80% of those 911 calls — 4 out of 5  — were for medical, not fire.
• Only 0.8% of calls were for structure fires, and only 8 of those had losses exceeding $20,000.
• 90% of calls were handled with one engine.
• The average call duration was 23.2 minutes, with 6 to 8 minutes of response time.
• The actual workload of an on-duty firefighter was 3.9 hours per 24-hour work period.

And despite all the chatter about how deadly a “volunteer” fire department would be, Arrula said Placentia’s new Fire and Life Safety Department would be a professional operation with professional firefighters and reserves who could help in a pinch. It would have two trucks in the city, just as OCFA did, each staffed with three rather than four firefighters. It would have two Lynch EMS ambulances carrying four trained and licensed paramedics on duty 24/7, an increase in lifesaving personnel.

OCFA’s service and firefighters are great, the city council concluded. But its model is costly and outdated. Despite intimidation and outright threats — mutual aid might be withheld by surrounding fire departments during a big emergency — the council decided that a local department controlled directly by the city would better meet its residents’ needs. Its goals were to reduce response time, improve fire prevention and improve quality of emergency medical care.

Four years down the road, the numbers speak for themselves. According to Placentia:

• Under OCFA, the response time for fire calls was 9 minutes and 30 seconds.
• Under Placentia’s new fire department, that shrank to 6 minutes and 21 seconds.
• Under OCFA, the response time for emergency medical calls was 9 minutes and 30 seconds.
• Under Lynch EMS, that shrank to 4 minutes and 48 seconds.
• Among cardiac arrest patients in Placentia, Lynch paramedics were able to restore a pulse 58.8% of the time in 2021-22 and 54.2% of the time in 2022-23 — more than twice the national averages.

On the fiscal front, this improved performance has saved the city more than $1 million each year over what it would have paid OCFA — savings that’s expected to average out to $3 million a year over the next decade as OCFA costs continue to rise. That’s real money over the long haul: more than $30 million saved by 2032, and close to $60 million saved by 2038, according to Placentia’s projections.

And overtime? The firefighter with the most overtime pay in Placentia earned just shy of $51,000 in OT — a fraction of what the top OT earners rake in at other agencies.

“It’s been an amazing few years,” an almost-astonished Walt Lynch of Lynch EMS told the city council earlier this month. “If you asked me back then if I’d be sharing this with you today, I’m not sure I would have said yes.”

Councilmember Rhonda Shader was mayor that night back in 2019, retaining poise in the onslaught of threats. “The nimbleness of this model, it’s turning out to be more than we hoped for,” she said.

Arrula was vindicated. “This is really amazing work when you talk about fundamentally saving lives,” he said. “Really unprecedented.”

Change

So what do all the purveyors of doom have to say about all this?

We reached out to several unions and union reps who had warned of death and destruction. No one was chatty on the record, but there was suspicion about the veracity of Placentia’s data.

Predictions that Placentia would be so weak it would need constant backup from surrounding agencies? The 2021 data showed 128 mutual aid calls into Placentia under the new department, versus 806 under OCFA in 2019. (It responded to 104 mutual aid calls in 2021 versus 457 in 2019; Placentia is now called upon less by its neighbors. A snub?)

In an emailed statement, OCFA said this:

“The OCFA recognizes that there are a few jurisdictions in the state that utilize non-fire-based EMS delivery systems due to their budgetary constraints. OCFA is fortunate and proud that our leadership supports a robust and proven Fire & EMS system that puts two firefighter/paramedics (along with two additional firefighters) to the side of our patients with speed, efficiency, competence, and care.”

The takeaway here is that there are other, more economical and efficient ways to deliver emergency services, but that the forces working against change are enormous. The old guard tried hard to thwart Placentia, asking surrounding cities not to enter into mutual aid agreements to help in emergencies, asking other agencies not to bid on Placentia’s fire and life safety contracts, threatening the city with lawsuits.

But change arrived nonetheless in Placentia, and it’s coming for everyone else.

“The DNA of fire departments is to respond to EVERYTHING and help EVERY TIME,” says a white paper called “21st Century Fire and Rescue,” co-chaired by retired Anaheim Fire Chief Randy Bruegman.

“While fires may be diminishing due to better engineering, codes and enforcement along with an increased focus on community risk reduction activities, calls for service are up for every department. These calls are for help, and the calls received today are much broader in scope. The services required often fall outside the traditional scope of fire and emergency services.”

Bruegman sees real opportunity here to deploy resources differently and more effectively, as has been done in Anaheim: sending nurse practitioners or behavioral health workers or community paramedics when that makes sense, rather than running four people on a 50,000-pound fire apparatus to everything.

“We need to look at what our statistics and data are telling us: Our demand for fire and rescue calls have gone down over the last 30 years, but call volume has skyrocketed,” he said. “It’s about how we address those calls in the most efficient and effective manner.”

As technology improves, precision will increase: Soon our wearable fitness devices will be able to transmit medical information to dispatch centers. Cars will alert first responders to traffic accidents. Smart buildings will send data instantaneously on emergencies.

“That’s going to change the way we do business in the future,” said Bruegman, president and founder of the Leadership Crucible Foundation. “There’s going to be a need for fire suppression, response and rescue for many, many years to come, maybe forever, but I think it will become a small component of our overall system.”

Many folks in Placentia agree. According to its most recent audit, the city that once teetered on the bankruptcy abyss had a 17% cushion for its general fund (for you numbers types, that’s a $7.2 million unassigned fund balance, compared to expenses of $42.1 million).

Back in 2012, that fund balance was in negative territory.

Green, the former city councilman who was on the dais when the decision was made back in 2019, had served on the OCFA board of directors and has great respect for the agency. “But Placentia doesn’t need helicopters. Placentia doesn’t need bulldozers,” he said. “We wanted our city to be fiscally sustainable, and now it is. We wanted to do this — and lo and behold, it works.”

Cayuga County (NY) official: AMR ambulance exit requires 'immediate solution'

Oct 29, 2023

By David Wilcox

https://auburnpub.com/news/local/cayuga-county-official-amr-ambulance-exit-requires-immediate-solution/article_1dbfed12-71cb-11ee-98d7-1b2f8ef7d8d2.html

Cayuga County is looking for "an immediate solution" after being told by American Medical Response last week that it will cease ambulance services in the area at the end of the year.

Riley Shurtleff, the county's director of emergency services, told The Citizen on Monday that the medical transportation provider responds to about 3,000 emergency and nonemergency calls annually.

To begin figuring out how to fill that void, Shurtleff has asked AMR to provide the county more detailed call response data. The provider operates one 24-hour rig and one 12-hour daytime rig from its Auburn station, he explained. Sometimes it responds with a full rig and sometimes with advanced life support intercept services for smaller providers, riding in their ambulances to the hospital.

That data will help the county "determine a path forward," Shurtleff said, in partnership with Auburn City Ambulance and the handful of other ambulance providers that will be left in the area.

"Those are conversations that will have to happen with agency chiefs and leaders in the very near future," he said. "We need to find an immediate solution in order to handle the call volume."

AMR, a subsidiary of Global Medical Response, confirmed in a statement to The Citizen on Monday that its Auburn operations will close effective Dec. 31. The private provider has served Cayuga County for more than 40 years. All local employees will be offered positions at its Syracuse operations, and AMR said it is "committed to a successful transition of services as determined by the county."

AMR said its decision to leave the county was made due to "stagnant reimbursement rates, rising costs of apparatus and medical supplies and the cost of a qualified workforce in a post-pandemic society."

Emergency medical services providers nationwide face similar problems, Shurtleff said. The fact New York state does not classify EMS as essential — meaning that municipalities don't have to provide them like fire and police services — exacerbates those problems, in his opinion. But he hopes that will change with a bill introduced to the state Senate in 2021 that would classify EMS as essential.

"There's potential for a reworked system out of this," he said, "but truly Cayuga County is seeing the local effect of health care and EMS systems struggling at a national scale."

What didn't play a role in AMR's decision, Shurtleff continued, was Auburn's creation of a municipal ambulance service in 2021.

Lon Fricano, who served as director of operations for the city service's predecessor, TLC Emergency Medical Services, said in a letter to the editor in The Citizen this week that the change "destabilized" local ambulance service and led to AMR's decision. He also accused the city service of "traveling to distant facilities while you may be waiting for an ambulance and AMR was being underutilized."

According to data received from the city of Auburn through a Freedom of Information Law request by The Citizen, however, city ambulance hospital-to-hospital transports have decreased since the creation of the new service. TLC averaged 70.7 transports a month in the 10 months of 2021 prior to the change, while Auburn City Ambulance has averaged 55.2 transports a month since.

Shurtleff said he thought the city's service "worked well" with AMR.

"I would actually say there were a number of times when AMR was covered by the city, and the city was covered by AMR," he said. "You can't predict when people have heart attacks."

The city service, and other ambulance providers in Cayuga County, now have a little more than two months to figure out how to work best together in the absence of AMR.

"EMS is a unique animal," Shurtleff said. "These additional agencies will have to look at their own structures to see where they can pick it up to move forward and continue serving the public."

Update to the news report shared yesterday….

----------------

Knox County recommends commission stick with AMR for ambulance service

Tyler Whetstone

October 26, 2023

https://www.knoxnews.com/story/news/local/2023/10/26/knox-county-recommends-commission-stick-with-amr-for-ambulance-service/71304332007/

The Knox County committee in charge of selecting an ambulance provider has decided to stick with its current provider, American Medical Response, despite wait times that have stretched to more than an hour for some patients and prompted Knoxville police and fire personnel to raise a public alarm about the problem.

The decision was announced Oct. 26. The recommendation must go through the Knox County Commission for approval before the current contract expires in January.

The county provided a copy of AMR's proposal after news broke of the committee's decision. As expected, the contract will require new subsidies to shorten wait times for patients in need of emergency care. AMR provided two options varying in cost from $2-$2.8 million annually, with a 3% annual increase built in.

The process for rebidding the county’s emergency services contract coincided with skyrocketing delays for service, including for some reasons that are out of control AMR, including understaffed emergency medical service systems and hospitals. Emergency rooms are overwhelmed by people using them as primary care, forcing ambulances to wait with patients because AMR policy does not allow them to leave patients until a hospital has taken over care. At the same time, hospitals are struggling to attract and retain health care workers.

These problems aren’t unique to East Tennessee, or to AMR. They're happening across the country as ambulance providers become the first option for residents who lack health insurance or a ride.

A third party hired by Knox County to review the situation, Fitch & Associates, said the current expiring contract is "financially nonviable." A Fitch representative told commissioners Oct. 16 the county will likely have to subsidize any contract by paying $1.9-$3 million each year.

"We all know that there have been some significant issues with healthcare and ambulance services – not only here but across the country," Knox County Mayor Glenn Jacobs said in a statement. "We put the current contract out to bid early because we realized, with 12 amendments already, it was becoming a hindrance to EMS services in the county. Though this new contract and its significant updates won’t immediately fix all the problems, we feel like it will be a big step forward.

"We still have high wait times at understaffed hospitals, but the new contract should help alleviate some of the associated issues, and, as always, we remain committed to working with all our partners to continually improve emergency access in our community," he continued.

How the committee selected the company

The committee in charge of reviewing the proposals was made up of five members, which included Colin Ickes, director of Knoxville-Knox County Emergency Management Agency; Jay Garrison, procurement coordinator from the county; Jennifer Ranson, an emergency medicine physician; Kevin Parton, senior director of the Knox County Health Department; and Steven Hamby, emergency response coordinator for the health department and chairman of the Tennessee Emergency Medical Services Board.

The committee scored each company on four segments: administration, operations, quality management and cost.

The total possible score was 5,000. This is how they finished:

• AMR: 4,761
• Priority: 4,124
• Falck: 4,060
• AmeriPro: 3,655

"Knox County ran a fair and focused process and we are thrilled to win the competitive process and be able to continue our long standing service to the citizens here," Brett Jovanovich, AMR's regional vice president of the southeast region, said in a statement.

"The new and much different contract will help address many of the problems plaguing the EMS industry nationwide and we salute the county for taking a different approach."

What’s next?

The ambulance contract has historically been a contentious vote for the commission and there’s no guarantee AMR has the six votes required to approve the contract at November’s meeting.

Regardless, commissioners’ hands are tied when it comes to suggestions or tweaks to the contract. Their only role in the process is to vote the committee's suggestion up or down. If they decide to reject it, the contract will require a rebid and the process starts over, which would take months.

To complicate matters, AMR’s current contract is set to sunset at the end of January. Even if AMR retains the contract, the current one would presumably have to be extended. If AMR's bid is not approved, it will take time to get a new ambulance service up and running.

Such confusion has precedent. In a heated ambulance contract debate in 2002, two Knox County Commission committees voted against awarding the contract to AMR, which won the rebidding process over Rural Metro, according to Knox News archives. Rural Metro had the contract the previous 17 years.

Weeks later, County Executive Tommy Schumpert removed a final vote on the contract minutes before the commission could take it up after Rural Metro filed a complaint with the county about how the procurement process was handled.

Schumpert originally supported AMR but later changed his tune, supporting Rural Metro instead. Months later, the commission approved a contract with Rural Metro. In the interim Rural Metro's original contract had to be extended so the county could continue receiving ambulance services.

AMR bought out Rural Metro in a 2015 deal worth over $500 million.