Calif. county saves millions by targeting frequent fliers
The county began handing out suspension letters to 911 abusers, and offers counseling and medical services to help them adopt healthier lifestyles
By Marc Benjamin
The Fresno Bee
FRESNO, Calif. — Fresno County used to be saddled by skyrocketing ambulance and hospital costs because of "frequent fliers" who called 911 hundreds of times a year for a ride to the hospital.
So the county came up with a "no-fly" list. Using a color-coded spreadsheet, the county ambulance services identifies the most frequent users and hands out suspension letters to the worst abusers.
The county also has improved its social services safety network, providing counseling and medical services that help former frequent fliers adopt a healthier lifestyle. Many are substance abusers or have mental health problems, and half are homeless.
Fresno County is among the first counties in the country to target and suspend frequent ambulance riders to get a handle on overuse. And it appears to be having the desired effect — ambulance calls for the most frequent users have declined sharply, saving millions of dollars and freeing medical personnel to answer other emergencies.
The suspension process, which began in 2012, is done in stages. Frequent fliers get three notices once they are identified. If they call for an ambulance 12 times in the following 90 days, they could be barred from ambulance rides unless a paramedic determines there is a true emergency. When they are handed notices, users also are told about the county's social services.
"My goal is, and always has been, to help them out of the system, not shut them out of the system," said Daniel Lynch, Fresno County Emergency Medical Services Department director. "That way they find help for whatever problem they have."
In the multipronged approach, Lynch's department gets help from the county's Department of Social Services, local hospitals, police and deputies, ambulance company employees and dispatch crews.
The policy was triggered after two homeless men got 1,363 ambulance rides to Fresno hospitals in 2011 — nearly 1% of all Fresno County's ambulance calls. The top 50, also called super users, tallied 4,367 calls for ambulances that year.
The problem was costing taxpayers millions of dollars in local emergency medical services when The Fresno Bee exposed the problem in a Watchdog Report in 2012.
The suspension program was delayed several months at the end of 2011 because county officials worried about potential liability if the patient had a serious condition or died after the ambulance left. After consulting with the county counsel, the county started the program.
Last year, the same top 50 took 913 trips to hospitals, and they likely will use even fewer rides this year, Lynch said.
"It was a full-court press," Lynch said. "The EMS agency went out and engaged those people."
The program has saved more than $3.9 million in federal, state and local funds in its first 18 months, he said.
In addition, the program reduces workloads in emergency rooms and keeps ambulances on the streets where they can quickly respond to other calls.
"The progress has been huge," Lynch said.
But even as officials identify super users and discourage ambulance abuse, new frequent users surface and require close monitoring.
When paramedics reach someone they suspect of ambulance overuse, they ask dispatchers if a potential rider is on the suspended list. If they are, paramedics conduct a physical exam and check that vital signs are normal. If so, and if patients can stand, they aren't transported to a hospital under the county's policy.
A physical exam takes a few minutes, but a ride to the hospital can sometimes take more than an hour of a paramedic's time.
Super users aren't cast aside, however. If a person is denied a trip to a local hospital, Fresno-based American Ambulance will call them back, said Todd Valeri, the company's general manager.
"Our dispatchers do a call back usually during normal business hours within two hours as a safety check as a way to manage risk," he said. "We get hold of 75% of them."
Eight people have been named to the no-fly list, but one super user died last year. Suspensions are doled out sparingly: Three were blacklisted in 2012, four in 2013, and one just last month.
A handful of others are in the "red" category, which means they are in jeopardy of being denied ambulance service.
By the time they get to the blacklist, they have been warned three times and advised of programs that can help them, medical clinics they can visit and other services available.
When Lynch learns the names of ambulance abusers, they are tracked, call by call.
He monitors the top 50 and another 40 on a watch list behind them.
Maintaining the list takes vigilance because somebody can start making a lot of ambulance calls virtually unnoticed.
Recently, Lynch's department realized a man had 122 hospital trips this year from different areas, including outside Fresno County. Before 2014, he had taken one ambulance ride over the past six years.
Daniel Duran, 44, who is homeless and a rail-thin 110 pounds on a 5-foot, 8-inch frame, roams downtown Fresno, limping from a sore Achilles tendon and a variety of leg injuries.
He was blacklisted at the end of July after his call total reached 140, Lynch said.
Pain has spread through his lower legs, Duran told The Bee. Since he recently had his cane stolen, he has lost most of his mobility and uses a shopping cart to keep himself upright to walk.
He described his pain as extreme and blames his downfall on drug and alcohol abuse, which he says "overpowers me, and I just can't stop."
Five years ago, Duran said, he weighed 250 pounds and was working as a security guard in Los Angeles.
"I am ashamed," Duran said when asked about his frequent use of ambulances.
He admits he has "kind of abused it, but I never called if it was a lie."
He used to call from Madera and Selma, but recently returned to Fresno so he could sleep and live near Community Regional Medical Center, because "it's the best hospital" in the area.
Even though he is a few blocks from the hospital, he is unable to walk there, he said.
An ambulance trip costs about $890 and a basic hospital checkup around $370.
When ambulance customers are non-paying or low-paying, the ambulance company has to shift uncompensated costs to those who are insured.
Each time a frequent user takes an ambulance to the hospital, those charges are almost never fully paid. Medi-Cal reimburses less than one-third of a $430 ambulance ride, said Valeri, general manager of American Ambulance.
According to county statistics, the new top 50 frequent users took 1,345 rides in 2013. If each got a checkup at the hospital, the price for ambulance service and the hospital visit would be about $1 million per year — a fraction of the $3.9 million it cost three years ago when the top 50 riders took more than 4,367 ambulance trips.
Although Fresno County's problems are not isolated, its program is not being duplicated around the state. Programs in San Diego and San Francisco emphasize funneling people into social services programs rather than threatening suspensions.
The problems around California vary, said June Iljana, executive director of the California Ambulance Association.
"The idea of banning people from using EMS is not something people are doing statewide," she said. "People are impressed (by Fresno County's program) but it just hasn't been something people have tried to implement locally because they have other things on their plates."
Besides, Fresno's problem may be unique, said Dan Smiley, chief deputy director of the California Emergency Medical Services Authority.
"In Fresno, these are some of the most extreme, hyper users we've heard about," he said.
Los Angeles County officials were interested in a pilot program that followed Fresno County's model, but the county's size, number of fire departments and disagreements over liability made it too unwieldy to attempt, said Cathy Chidester, Los Angeles County's emergency medical services director.
Getting agreement across a county with 88 cities, 73 hospitals and 30 fire departments was an issue, she said. Many of the county's fire chiefs were concerned about potential liability and vetoed a pilot program Chidester had suggested.
"We haven't been able to get to the next step," she said. "But, it's on the radar."
The state EMS authority's Smiley, who was Fresno County's EMS chief from 1984 to 1989, said county officials can use the state Health and Safety Code to keep people from abusing services.
"The local director has broad latitude in terms of determining patients for triage," he said. "I know they have gone through a great deal of thought in making this determination."
Peter Vargas, 72, of Clovis, describes himself as a former frequent ambulance user. He was in the top 30 in 2012 with 47 ambulance trips before curtailing sharply in 2013 with just 19 trips. In the past six years, he rode in an ambulance to the hospital 223 times.
Vargas, who uses a walker because of a bad knee, took a life skills class at Central Valley Regional Center at a caseworker's suggestion and proudly talks of having an apartment and a way to pay for his medicine.
He said he now takes a bus to the hospital or his doctor, but the biggest reason for his reduced ambulance use was getting a breathing machine to treat his asthma after another machine broke.
Lynch is encouraged that Vargas is making fewer calls for an ambulance, including not asking for an ambulance when he runs out of medicine.
"He has been doing better considering where he was," Lynch said. "He's cut back quite a bit."
From 2008 to early 2013, Ernest Yetter, 54, was a conspicuous ambulance user — he called for one 314 times.
Yetter, who was in and out of jail for being drunk and disorderly, said his friends often dragged him from the street to a sidewalk where police called an ambulance.
"Most of the time I was on a sidewalk, in the gutter or in the middle of an intersection and I couldn't even move," Yetter said. "I cracked my head so many times I can't even count."
In early 2013, he got help. A social worker from Community Connections at Community Regional got him enrolled in an alcohol rehabilitation program and found Yetter a place to live.
Community Connections workers meet with people who come to the emergency room regularly and try to find ways to reduce their use.
Today, he lives on his own, works occasionally, goes to church and visits his old friends on the streets to preach about God and urge them to go to recovery.
Community Connections case worker Marlene Warren said it took about two years before Yetter wanted to change, let alone talk to her. Yetter credits Warren and his church for his sobriety and new lifestyle. He is reconnecting with his family and sees his grandchildren.
Warren considers Yetter, who has been sober almost two years, a top pupil because of the huge strides he has made in such a short time.
But she knows her persistence also was important. Before he agreed to get help, Warren said, she asked Yetter to consider it 60 or 70 times at his old haunts at First and Tulare streets or at the hospital.
"He would see me, pull out all his tubes, run the other way and say he needed a beer," Warren said.
But one day he finally walked up to her and asked for help. Without it, Yetter said, he knew he would die soon.
She got him admitted to WestCare for a six-month rehabilitation program and then found housing for him.
"It just takes one day when they decide they want to change," Warren said. "He is definitely amazing; I just happened to be there."
Community Connections also works with Cesar Arana, the top ambulance user in 2011 with 710 ambulance calls.
This year, Lynch said, Arana has called for an ambulance 48 times and been taken to a hospital seven times.
Benjamin Greene, 34, was blacklisted last July because of excessive ambulance use and also arrested for calling 911 too often. He had called 62 times this year and was taken to a hospital 18 times. Since 2010, he called for ambulances 356 times, according to county records.
He was homeless for 18 months, but three months ago he got an apartment through Turning Point in southeast Fresno. He no longer calls for an ambulance.
"I would just get these panic attacks," Greene said.
Calling the ambulance would calm him down because he knew help was on the way.
He said he used marijuana and methamphetamine, which likely contributed to his panic problems.
Fresno County public health officials and Community Connections case worker Adriana Ramirez helped Greene sign up for housing and public financial support.
Greene now looks to Turning Point counselors and Ramirez to help him with his anxiety.
And, Ramirez gave him rules for calling the ambulance — only when he is "actively bleeding, not breathing, missing a limb or actively on fire."
So far, Greene has heeded her warning.
"There is no calling the ambulance and no calling the police," he said. "There's an alternate way of coping ... staff here (Turning Point) helps and it fixes the problem."
Eventually, Greene wants to return to work in food service or hotels, but for now he is glad to be in a safe, quiet place. "Even to this day I am so happy to be here," he said. "I am like a normal person now."
To keep Yetter and Greene off the streets costs about $1,000 per month, much less than the thousands of dollars it could cost monthly for multiple ambulance rides and care in the hospital, Warren said. It also frees up hospital bed space, emergency teams and ambulances.
"It's not permanent, it's supportive housing for now," Warren said. "It's just while they get stabilized and on their feet."
Lynch, whose policy resulted in Greene's suspension from ambulance use, was glad to learn about his progress.
"It's good to know these guys are getting help," he said. "That makes my heart feel good."
©2014 The Fresno Bee (Fresno, Calif.)
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