By Jim Doyle
The San Francisco Chronicle
SAN FRANCISCO — State officials have revoked the San Francisco Fire Department’s lock on emergency ambulance services, a move that is expected to force city officials to put those services to competitive bid, according to documents obtained by The Chronicle.
The decision, which cited the lack of competition among San Francisco’s 911 medical care providers, comes as the California Emergency Medical Services Authority is pressing counties across the state to improve the quality of patient care. State regulators zeroed in on San Francisco’s ambulance system when recently inspecting the city’s emergency medical services plan.
Many California counties, including Alameda, Contra Costa, Santa Clara, San Mateo and Solano counties, have put pre-hospital emergency services out to bid in recent years, and many counties have contracted with private ambulance firms to deliver 911 medical services under strict performance standards.
In a series of reports, The Chronicle has raised questions about the quality of 911 medical care in San Francisco after finding that first responders arrive late in about 27 percent of the most urgent medical cases - falling short of the city’s goal for help to arrive within 6 1/2 minutes after receipt of a 911 call involving a potentially life-threatening emergency.
Virtual monopoly
For the past decade, the San Francisco Fire Department has enjoyed a virtual monopoly in providing emergency ambulance services. But the decision by state regulators could compel the fire chief to demonstrate that her agency is the best qualified to deliver quality 911 medical care.
“If the state requires us to go out to rebid, we will go out to rebid,” said Dr. Mitch Katz, director of the San Francisco Public Health Department. But he stressed that the state’s ruling turns on “a very narrow legal question that’s based on an esoteric statute. ... The state’s letter itself is a little puzzling, so I’m having the city attorney review it.”
In a July 31 letter to Dr. John Brown, the city’s emergency medical services director, California Emergency Medical Services Authority Director Steve Tharratt rescinded San Francisco’s long-standing antitrust immunity in running its 911 ambulance operations and advised city officials to begin a competitive process. He made his ruling after the city submitted 127 pages of documents.
Bonnie Sinz, the state’s EMS systems division chief, said the Fire Department as well as any private ambulance companies interested in providing 911 emergency services in San Francisco would be expected to participate in the public bidding process.
The Fire Department has been the primary provider of 911 medical services in San Francisco since taking over the ambulance fleet from the Public Health Department in 1997. Firefighters and paramedics are dispatched by the city’s 911 Call Center.
Private ambulance firms handle fewer than 2.4 percent of the city’s 911 ambulance services, down from about 20 percent in the late 1990s, state officials said.
“The ambulance service in the city has a long, rich tradition,” said Fire Chief Joanne Hayes-White. “In my opinion, it’s something that works very effectively.”
Emergency medical consultant Mike Williams, who helped develop California’s emergency medical standards, said private ambulance companies have succeeded in delivering a highly flexible emergency response in some cities, putting more ambulances on the street during peak hours.
Accountability
“Where you would see improved quality is in a higher confidence level that an ambulance would arrive in a certain number of minutes - based on a written performance standard that they have agreed to,” Williams said. “With a franchise, you can hold an ambulance provider accountable to a much more precise standard.”
But there is no silver bullet, he said. San Jose, San Diego and Seattle rely on partnerships between fire agencies and private ambulance firms to deliver 911 medical services. Boston, Denver, and Austin, Texas, provide these services through a “third service” public agency that is not a fire department.
“A community deserves to have high-level ambulance service, because that’s what they’re paying for,” he said, “and if they’re not getting it, that’s when they should be asking a lot of questions.”
For decades, state officials had granted San Francisco an exemption from federal antitrust laws in operating its emergency ambulance system. But after close inspection, they determined that the city was no longer qualified for that exemption because of significant changes in its system since 1981, when the state enacted laws for emergency medical services.
In recent years, 911 medical care in Oakland, San Jose, Monterey, Riverside, Los Angeles, Santa Barbara, San Luis Obispo and San Diego has been put to bid.
Such competition among providers, experts say, helps ensure that taxpayers receive quality care at a reasonable cost by holding public officials and ambulance providers accountable. If a public agency or private ambulance firm delivers substandard care, that agency or firm is less likely to receive a contract when the services are rebid. Many contracts also include financial penalties for slow 911 ambulance responses.
Suburban communities have relied increasingly on private ambulance firms to deliver emergency pre-hospital services. But it can be difficult, experts say, for private providers to turn a profit in an urban area where so many patients are uninsured - unless their ambulances simply provide backup service for a fire department or public health agency. Private ambulance firms may also place a premium on profits and, in some circumstances, may be less accountable to the public.
David Nevins, president of the California Ambulance Association, said: “Going out to bid can be a costly endeavor. There may be some alternatives to just jumping in. ... First, you would want an impartial evaluation system by an industry expert to identify the strengths and weaknesses of a system and make a recommendation to the governing body.”
Competitive process
Federal antitrust laws, which apply to local government as well as businesses, discourage the creation of monopolies and restrict price-fixing by service providers. State law allows local agencies to choose emergency ambulance providers “if a competitive process is utilized to select the provider or providers of the services.”
An exception to this rule, known as a grandfather clause, allows an antitrust exemption to a jurisdiction “that continues the use of existing providers operating within a local EMS area in the manner and scope in which the services have been provided without interruption since Jan. 1, 1981.”
Tharratt wrote on July 31 that “it is our determination that San Francisco is not eligible for grandfathering” because of what he called “multiple changes” to its emergency ambulance service in the past 27 years.
Brown, who heads the San Francisco Emergency Medical Services Agency, had told state officials in a June 3 memo that he “cannot determine in good faith that there have not been one or more material changes in scope and manner” of the city’s 911 ambulance services since 1981. He cited several changes, including the number and continuity of ambulance providers and the declining number of 911 calls handled by private firms.
San Francisco officials had not sent an emergency medical services plan to the state since 1999, although state law requires the submission of a revised plan each year. When city officials submitted one in March, state regulators focused on San Francisco’s lack of competition for 911 medical care.
“A community deserves to have high-level ambulance service.”