By Jerome Wright
The Commercial Appeal (Memphis, TN)
Copyright 2007 The Commercial Appeal, Inc.
MEMPHIS — Thirty-one minutes.
That’s how long it took last October for a Rural/Metro ambulance to respond to an emergency call at Avenue Carriage Crossing. A shopper had collapsed and the Rural/Metro ambulance stationed in Collierville was on another call.
Collierville’s Fire Department paramedics (also called first responders) were there in less than four minutes, but it took a Rural/Metro ambulance 31 minutes to arrive from Lakeland to take the shopper to the hospital. She died.
Emergency medical service (EMS) officials across the country say such response time glitches occur occasionally.
But perception is everything.
Those 31 minutes have brought to the forefront complaints that Shelby County is not getting its money’s worth from Rural/Metro.
Those 31 minutes have set off an EMS chain reaction:
Shelby County Mayor A C Wharton decided to opt out of the last year of Rural/Metro’s contract and let bids for EMS ambulance service.
Collierville and Germantown are seriously considering partnering to contract for their own ambulance service.
Wharton is pushing a long-range plan for a countywide EMS operation that would include overhauling what he feels is an inadequate EMS dispatch system and hiring more paramedics.
The county’s request for proposals (RFP ) for ambulance service is not an indictment of Rural/Metro, Wharton says. But with the contract coming up for renewal and public concerns about service, the mayor felt the time was right to fix the county’s EMS system once and for all.
“There was a public outcry. When there’s a public outcry, that’s how you get things done. I’m into my last term (as county mayor) and I want to get this done before I leave office,” he said.
Rural/Metro nationally
Ambulance service in the United States is big business and Rural/Metro is a major player.
How big is the industry? Rural/Metro’s Investor Presentation for the fiscal year that ended June 30, 2006, said the medically necessary ambulance market is estimated to be worth $7 billion to $10 billion annually. Rural/Metro is the nation’s second largest provider of ambulance service, with 17 percent of the market. American Medical Response is the largest, with 33 percent.
Rural/Metro is in about 40 communities in 23 states. In some communities, they also provide firefighting services, including providing firefighting services for Federal Express in Memphis.
The investor’s report shows the company had net revenue for the fiscal year that ended June 30, 2006, of more than $548.5 million. That was up from more than $501.51 million the previous year.
911 and non-emergency, medically necessary ambulance transportation represented 88 percent of net revenue. And, the report states, the future looks bright. Market dynamics such as growing demand for ambulance services beyond EMS and aging baby boomers portend continuing growth.
Rural/Metro locally
Locally, Rural/Metro has a $1.01 million contract with the county to provide ambulance service for unincorporated Shelby County, Arlington, Collierville, Germantown, Lakeland and Millington.
Memphis and Bartlett have their own EMS systems.
The contract calls for Rural/Metro to have six ambulances on duty and three in reserve. The county decides where they’re located: On Forest Hill-Irene Road, and in Collierville, Germantown, Arlington, Millington and Northaven.
The ambulances are dispatched through the county Fire Department’s 911 system.
Glenn Miller, Rural/Metro division general manager, said Rural/Metro is receiving an undeserved black eye.
“We’re doing what we’re supposed to do. We’ve always known what they wanted and we’ve given it to them. The new RFPs (requests for proposals) are not because of anything we’ve done or haven’t done,” Miller said.
Miller and Wharton don’t disagree on that point. Based on the number of calls Rural/Metro receives, response-time problems have been few, Wharton said. They also don’t disagree on two other points that will be key considerations for companies offering ambulance service proposals to the county.
As the population outside Memphis continues to grow, so does the number of ambulance calls. The number of ambulances hasn’t grown. Miller said Rural/Metro averages about 650 911 transports a month, and 950 to 1,000 hospital-to-hospital transports a month.
Industry officials said hospital-to-hospital service is a very lucrative component of the ambulance business because of third-party payers such as family members, insurance companies, Medicaid and Medicare.
The other issue is spacial. The contract with Rural/Metro has only six ambulances covering 310 square miles. That compares with Mesa, Ariz., population 440,000, where Rural/Metro has 16 ambulances covering 129 square miles, said Bill Hayes, deputy chief for emergency medical services for the Mesa Fire Department.
In Aurora, Colo., population 310,000, Rural/Metro serves a 154-square-mile area, Fire Chief Casey Jones said. Jones, who has worked for both private and government EMS operations, said covering that much territory will, on occasion, result in slower than normal response times.
As the uproar over the Collierville incident was churning, Wharton asked Rural/Metro what it would take to guarantee a response time of about nine minutes or less. Rural/Metro said it would cost about $3.2 million to add enough ambulances to meet that goal.
Asked if Rural/Metro would submit a new bid for EMS service, Miller said “it depends on what the RFP looks like.”
Cherry-picking
If Collierville and Germantown stick to their decision not to join a countywide EMS system, it could complicate Wharton’s long-range EMS plans and have a significant financial impact on the rest of the county, something Arlington Mayor Russell Wiseman expresses concern about in a guest column today on this page.
“If they are not part of the contract, it’ll drive up the subsidy (the county will have to pay the contractor). You can’t reduce the number of ambulances, but without Germantown and Collierville the amount of revenue will decrease,” said Rural/Metro’s Miller.
Jon C. Altmann of Phoenix, an EMS consultant with more than 32 years of experience in public safety emergency services work, has been following the Rural/Metro story in Shelby County from a public policy standpoint.
“From the demographics of Germantown and Collierville, I’d love to have their business, an exclusive contract,” said Altmann, who is also managing editor of FireTimes.com, an electronically published professional journal covering both news and technical issues in fire service and emergency medical services. He said he is a “minor” Rural/Metro stockholder.
Two things make the two cities extremely attractive: a high-density population in a relatively confined area and plenty of third-party payers.
“Non-emergency ambulance service equals instant cash,” Altmann said. That means that the cities likely would not have to pay an ambulance company a subsidy. It’s also possible that Collierville and Germantown could get a deal similar to Aurora’s, where Rural/Metro pays the city a subsidy.
“They pay us $500,000 a year to support our costs in assisting them. They’re willing to do that because Aurora has enough of a payer mix to make it profitable for them,” said Jones, the fire chief.
He added, “Here’s what I think is going to happen (in Shelby County): If I can carve off the good stuff (Germantown and Collierville), I’m going to make money. But what about all the folks out there in the rest of the service area? If they (the county) lose the part with the good payer mix, then it makes it harder to find someone to come in, unless the county is willing to pay a big supplement.”
Altmann concurred. “Germantown and Collierville pulling out will gum up the deal” as the county seeks a new ambulance contract.
Seeing the bigger picture
Altmann, Jones and others fear the “public outcry” has the county, Germantown and Collierville rushing to fix a problem without looking at all the ambulance contract service models.
“It doesn’t look good when you have people dying waiting on an ambulance,” Altmann said. “Shelby County and those two cities have choices. . . . What I’m seeing now is that instead of running to a choice with confidence, they’re running with sweat and trepidation toward a fix-it-now choice.”
That’s not so, said Wharton.
“If by the end of June (when Rural/Metro’s contract expires) we don’t have a deal worked out (with a company), we’ll go month to month. We’re not going to make any rash decisions.
“The RFPs will give us the opportunity to look at a whole lot of options,” he said.
And if Collierville and Germantown go their own way? “We’ll still go forward and tailor a plan to service what’s left,” he said.
He agreed, though, that losing Collierville and Germantown could increase ambulance costs for the other towns and the county.
The heart of the problem
Wharton said the key to fixing EMS response times is fixing the 911 dispatch system, which he called inadequate.
“We’re just not getting the right information to them because . . . there are too many layers” in the dispatching process, the mayor said. “The system needs to be more centralized before an ambulance is dispatched. What we’re focusing on is how do you eliminate some of the layers?”
With so many people handling a call before it’s received by Rural/Metro, said Wharton, “there’s always a danger that the right information won’t be passed on. Sometimes you lose three to five minutes on some calls (because of the way the calls are routed) and Rural/Metro gets blamed for it.”
The ideal system, he said, would have the 911 call go straight to where the ambulance that would answer the call is located. That, ideally, would be coupled with a global positioning system (GPS) pinpointing the location of each ambulance.
Building trust
For Collierville and Germantown officials, the ambulance issue is about control and accountability.
To keep them in the EMS corral, Wharton said, “we have to build trust with the right (EMS) performance mechanism, so that we can assure them they’re going to get the best service, and if something happens (the ambulance provider) will be dealt with as if they were under (Collierville’s and Germantown’s) noses.
“It can work, but you’ve got to have that level of trust. . . . We’ll all be better off if we can do this. . . . (We need) to let people know we’ve got your back if you need an ambulance. We can’t say that now.”
Wharton believes there is another important point that is getting lost in the ambulance debate.
He explained that easy mobility means that people frequently travel outside their cities’ boundaries. What happens when they’re outside their cities and they need an ambulance?
“There needs to be good ambulance service for everybody, not just in your particular city,” Wharton said.