Updated February 2015
After losing $21 million during the first two years of operations in Alameda County, Calif., Paramedics Plus was given the OK to amend the terms of its five-year 911 contract with the county, including hiking ambulance transport fees and simplifying the compliance measurement and penalty structure.
The Alameda County Board of Supervisors approved a transport base rate hike from $1,604 to $1,895 and a mileage increase from $36.91/mile to $45/mile. The amended contract will also reduce response time fines in certain circumstances and simplify the response time measurement structure, says Dale Feldhauser, chief operating officer for Paramedics Plus in Alameda County.
The changes should help the company get out of the hole in Alameda by year four of the contract, Feldhauser says. “We’ve lost money both years of the contract and we’re probably going to lose money the third year,” he says. “Do we have to break even? Yes. Are we there yet? No. But we’re getting close.”
Since taking over the Alameda contract from longtime provider American Medical Response on Nov. 1, 2011, Paramedics Plus has experienced a revenue shortfall, bringing in millions less than projected in the RFP that landed them the contract, according to recommendations submitted to the Board of Supervisors by Alex Briscoe, director of the Alameda County Health Care Services Agency. Reasons for the shortfall, according to Briscoe and Feldhauser, include:
- Capital outlays such as buying 110 mechanical CPR devices for fire departments, state-of-the-art defibrillators and a sophisticated electronic patient care reporting system
- A shift in payer mix, with fewer patients having commercial insurance and more paying with Medi-Cal, California’s Medicaid program
- A complicated response time measurement structure, with Paramedics Plus incurring large penalties for relatively minor violations
Using insurance data from 2007–09, Paramedics Plus projected its payer mix would include 34% Medicare patients, 12% Medi-Cal, 27% commercial insurance and 27% private pay, many of whom are uninsured. But as the economy deteriorated, payer mix shifted, with far more Medi-Cal patients and far fewer patients with commercial insurance, Feldhauser says. During fiscal 2011–12 (Nov. 1, 2011, to Oct. 31, 2012), actual payer mix was 35% Medicare, 24% Medi-Cal, 20% commercial insurance and 22% private pay.
That 7% drop in commercially insured patients played a large role in Paramedics Plus bringing in $10.5 million less in revenue in fiscal 2011–12 than projected, Feldhauser says. Total losses for 2011–12 were about $12 million, or $48 million total revenue and $60 million in expenses. The exact figures for fiscal 2012–13 are still being compiled, he says.
Another issue working against Paramedics Plus, according to Briscoe, was that its contract with the county included “significantly more stringent response time compliance standards” than the contract with AMR, including boosting the number of response time zones from five to 61. (Paramedics Plus is responsible for 911 ambulance transport in four zones, which are divided into several subareas—urban, suburban, wilderness—which have multiple response time criteria depending on the urgency of the call.) Though well-intentioned—the goal was to encourage more consistent response time performance county-wide—the change had unintended consequences, Briscoe says.
With some subareas having a call volume in the single digits, one late call could result in non-compliance for that zone, resulting in fines as high as $50,000.
During the 19 months leading up to October 2013, Paramedics Plus was fined $1.3 million for response time violations—even though the overall compliance on 194,000 calls was 97.9%. In September, for example, a Paramedics Plus unit arrived to a Charlie level call in a wilderness area with a response time of 28 minutes in 30 minutes, 21 seconds. Those two minutes and change cost Paramedics Plus $35,000.
To avoid penalizing Paramedics Plus in areas with low call volume where one late call can cause them to miss their targets, Alameda County will now measure compliance when the agency has responded to 100 calls in a subarea. Also, the number of zones/subarea measurements will be reduced from 61 to 48. “It should be noted that response time requirements are not changing; all response time requirements will be maintained at current levels,” Briscoe wrote, noting that Paramedics Plus consistently meets or exceeds standards. Penalties for outlier calls will also be reduced as long as Paramedics Plus is hitting a 90% or better overall response time in that subarea.
The change in penalty structure should drop response time fines to about $200,000 in fiscal 2013–14, Feldhauser says. That, plus the higher fees and continued improvements in operational efficiencies, should help Paramedics Plus reach profitability by year four, Feldhauser says.
Paramedics Plus is a for-profit subsidiary of the nonprofit East Texas Medical Center in Tyler, Texas. The Alameda contract is Paramedic Plus’s first in California. The contract runs from Nov. 1, 2011, through Oct. 31, 2016, with an option of a five-year extension.
To read Briscoe’s recommendations, go to tinyurl.com/n22pvcl and choose the attachment under Agenda Item 1.
Cardiac Arrest Survival Hits 57% in Seattle
Seattle and King County, Wash., continue to raise the bar for sudden cardiac arrest response, with survival for witnessed cardiac arrest in which the patient had a shockable heart rhythm reaching 57% in 2012. The survival rate was 22% for all types of out-of-hospital cardiac arrest in which resuscitation was attempted, according to the Seattle and King County Division of Emergency Medical Services 2013 annual report, released Sept. 4, 2013.
In 2012, the King County EMS/Medic One system responded to 172,700 911 calls, including 48,010 for ALS. Of those, 1,134 were cardiac arrests in which resuscitation was attempted, including 983 who arrested before EMS arrived and 151 who arrested while EMS was on scene.
According to Seattle–King County statistics, patients with bystander-witnessed arrests due to underlying heart disease and with a rhythm of ventricular fibrillation had the greatest chances of survival. Males were more likely to survive to hospital discharge and were more likely to have heart disease as a cause of the arrest. Survivors’ average age was considerably younger than non-survivors (58 compared to 65). Survivors were also somewhat more likely to receive bystander CPR. In half of cases in which bystanders initiated chest compressions, they had received instructions from 911 dispatchers.
Rapid defibrillation is a key element of SCA survival, but awareness was low among the public, as many people didn’t realize they needed to register their AEDs per state law so dispatchers could locate the nearest device. To increase awareness, the King County EMS/Medic One system launched Shockingly Simple–Restart a Heart Campaign, which led to 256 new AEDs being registered.
Read the full report at tinyurl.com/3tw389d (under the “What’s New at King County EMS” banner toward the bottom of the page).
