In the city of North Las Vegas, firefighters are facing the prospect of layoffs as the city tries to cut $33 million from its 2011 budget. To protect those jobs, the fire chief has proposed that his workforce take over transporting the most critically ill patients to hospitals, a job now mostly handled by a private ambulance service, MedicWest, which is owned by American Medical Response (AMR).
Elsewhere in Clark County, Nev., a task force charged with finding ways to cut county spending has called into question the dual response model, in which both the Clark County Fire Department and MedicWest/AMR respond to 911 calls. The task force is recommending that only private ambulances be sent in some situations, according to the Las Vegas Review-Journal.
And in Yakima, Wash., plans by the fire chief to train firefighter/EMTs as paramedics has sparked controversy, with some in the community claiming the move would drive the fire service into the ambulance business and force taxpayers to foot the bill for a service already provided by AMR and Advanced Life Systems, a locally owned private agency, according to the Yakima Herald.
Across the nation as municipalities struggle to trim budgets, fire departments are coming under increasing pressure to either make cuts or find ways to generate more revenue. In some cities, including North Las Vegas, the competition for business has pitted fire service-based EMS and private ambulance services against one another in what amounts to a territorial dispute: Fire departments want to make sure they are fully utilizing firefighters to ensure that they continue to receive community support and resources to maintain a ready workforce, while private ambulance companies are trying to protect their hard-won franchises and contracts, the viability of which they say are largely dependent on being able to seek reimbursement for transporting patients.
In August of last year, the International Association of Fire Fighters (IAFF) and the International Association of Fire Chiefs (IAFC) added fuel to the fire by issuing a joint statement calling fire service-based EMS “the most efficient and effective model for the rapid delivery of all emergency medical services.” Prehospital 911 emergency response is an “inherent government function,” the statement says. “When time is critical and effective pre-hospital care is necessary, the fire service is well positioned strategically, geographically, administratively, financially and operationally.”
The statement set off a flurry of heated discussions among the nation’s EMS providers—even among those in the fire service, some of whom expressed dismay that the IAFF/IAFC would seemingly be openly critical of their non-fire-based colleagues. Though IAFF/IAFC officials say the statement is directed specifically at for-profit private ambulance services, some who work within other EMS provider types—nonprofit privates and third-service agencies, among them—have taken issue with the statement.
“There are a lot of really creative ways people are doing EMS all across the nation, from really small organizations to really big ones, and I have not seen any research that shows there is one way that is better than the other,” says Aarron Reinert, executive director of Lakes Region EMS, a private, nonprofit ambulance service that serves 450 square miles in suburban and rural Minnesota.
Lakes Region EMS is both highly efficient and effective, Reinert says. His agency has been recognized not only for excellence in responses to natural disasters but also for its fiscal transparency, which includes a yearly independent audit.
“Being a not-for-profit and not receiving any tax subsidies forces our organization to be as efficient as possible, as responsive to our community as possible and very accountable,” Reinert says. “There is no steady stream of income unrelated to performance. By no means do I suggest a fire-based EMS organization isn’t similarly accountable; it certainly can be. But we have to earn every single one of those dollars we receive.”
‘Attacks’ on fire service
Despite the controversy, in interviews, the IAFF and the IAFC have defended the statement. Gary Ludwig, deputy fire chief in Memphis, Tenn., and chair of the IAFC’s EMS section, says the IAFF/IAFC needed to voice its support for members who are facing challenges from for-profit private ambulance companies that are making claims to cash-strapped municipal governments that they can do the job more cheaply and thwarting efforts by fire departments to do more for the communities they serve.
“The statement is mainly in response to attacks on fire-based EMS systems from private agencies,” Ludwig says. “We’ve had some members trying to do more for their communities by getting involved in first response and have been buffeted by private agencies.”
With firehouses strategically placed in the community, the fire service is uniquely positioned to serve as the nation’s first responder, says John Sinclair, immediate past chair of the EMS section of the IAFC and fire chief for Kittitas Valley Fire & Rescue in Ellensburg, Wash. In many cities—even those with public-private partnerships—firefighters are the first to arrive on scene, he says. “There are many fire departments that want to have an emerging role in EMS because they believe it is consistent with their mission to take care of the community,” he says.
Yet not everyone sees the fire service’s shifting focus to EMS in quite the same way. Some have remarked that loss of life and property in fires has declined in recent decades, thanks to smoke detectors, interior sprinklers and more fire-safe building codes. In the early 1970s, about 6,200 people a year were dying in fires, according to the U.S. Fire Administration. (The original estimate in the 1972 report “America Burning” was 12,000 deaths a year, but that was revised downward in later years.) Between 1999 and 2008, fire deaths had fallen to between 2,600 and 3,500.
With fewer serious fires, there is less for firefighters to do, some say, while medical-related 911 calls are soaring. Firefighters, once content to let private ambulances handle the transport, want to get in on the action now that they are having to fight for their own once-sacrosanct budgets, they claim.
Public-private partnership strained
For years in North Las Vegas, the fire department and MedicWest worked side by side, with MedicWest doing most emergency transports. That relationship became strained after the city council gave the fire chief a directive to generate revenue or cut costs, says Bruce Evans, assistant chief of North Las Vegas Fire.
One solution to the edict was to take over transport for the most critical patients for whom seconds counted, such as those suffering from cardiac arrest, serious stroke, stabbings or gunshot wounds who needed advanced life support. Those calls accounted for about 15 to 20 percent of the total transports, Evans says. By going this route, the fire department could both improve continuity of care and bill for those calls.
From a patient perspective, the move would make sense. More often than not, the fire department arrives on scene first. While MedicWest is permitted to meet a 11:59 response time based on its franchise agreement with the city, the fire department tries to meet a 7:59 response time, which it met 90 percent of the time in the most recent quarter, Evans says. “Most of the time, we’re there in six minutes,” he adds.
According to Evans, MedicWest billed $14 million servicing North Las Vegas last year. Allowing the fire department to take over a portion of the calls would generate about $3.4 million for the department and avoid the need to lay off approximately 16 firefighters—including Evans himself.
But MedicWest and AMR opposed the change. “The reality is we have a very effective and efficient system there, as far as response times and cost,” says Manuel Navarro, AMR’s vice president of EMS system deployment. “What was going to happen in North Las Vegas was [the EMS system] would end up being less efficient because it would cost the city more for the same level of service.”
In its editorials, the Las Vegas Review-Journal called the fire department’s efforts a way to “generate more hours of actual work and thus justify their highly paid jobs.” As of March, the city council had tabled the issue.
EMS: business or public service?
Dollars aren’t the only way to measure efficiency or effectiveness, Evans says. “Public safety is an essential government function, and it can’t be measured as a business,” he says. “There can be a good public-private partnership. But in this case, the greed on the private side is outweighing the good of the community.”
Sinclair agrees. In other communities, some private ambulance firms have simply packed up and left if they weren’t making money—something, he says, the fire service would never do. “They are not serving the community. They are serving the profit motive,” Sinclair says. “There is nothing that ties any private ambulance company to their community. If they go away, the fire department is still going to be there.”
But Navarro, who served 42 years in the fire service, most recently as fire chief in Colorado Springs, Colo., takes issue with the contention that private ambulance services are not sufficiently community-oriented. AMR’s workers live in their communities and participate in community events, he says. Their EMS training is comparable to that of fire-based providers, as is their dedication to their work. Their industry is highly regulated, with local officials having the ability to fire them if they are not performing up to standards.
“We have customers. Those customers are our patients, and if we don’t rise and meet the satisfaction of our patients, we are out of business,” Navarro says. “Do we have to be responsible to our investors? Absolutely. But if we are not keeping our customers happy, we are going to hear about that very quickly.”
It’s hard to argue with the fact that private ambulance service costs less, which is increasingly a concern as the need for emergency medical care is expected to rise along with the aging population, Ludwig concedes. In Las Vegas, unionized firefighters are paid an average of $113,000 a year, according to a review of payroll data by the Las Vegas Review-Journal. This compares to about $60,000 a year for paramedics at MedicWest. (Evans notes that the firefighter figure also includes overtime; the department concluded it was less expensive to pay OT than to hire additional firefighters.) And while private ambulance service is largely supported by user fees, firefighters are generally supported by tax dollars.
“I guess you can always buy something cheaper, but there is a question of quality,” Ludwig says. “We don’t have to service two masters. We don’t have to serve shareholders and the community. We only have one mission, and that’s the community.”
Despite such tensions, Navarro notes that there are many communities nationwide in which public-private partnerships are working well to serve the needs of the community. “There are things the fire service does really well, and we need to appreciate that. There are things we do really well. We have lots of communities where we work side by side with our best partner, which is the fire service.”
To Skip Kirkwood, chief of Wake County (N.C.) EMS, the entire conversation about which type of provider is more or less effective and efficient is counterproductive. EMS evolved into a system in which prehospital care is being offered by a hodgepodge of provider models based on what communities wanted and what they could afford, a situation not likely to change anytime soon, he says. Whether it’s a fire-based, private or third service, profit or nonprofit system, the bigger issues are common to all in EMS: improving Medicare reimbursement; increasing federal funding for readiness; investing in new technology, planning and training for major incidents; improving safety of crews and patients; encouraging a fitter and healthier workforce; and expanding the role of EMS to help solve the escalating costs of providing the nation’s massive health care needs.
To make headway on those issues and to move EMS into the future, EMS needs to speak with one voice, advocating for changes that will impact all of EMS, their patients and communities, according to Kirkwood. “As mature leaders within the EMS community, we do better working together than fighting against each other,” he says. “Ninety-five percent of the issues we have are common to all of us. The statement takes people away from the 95 percent and focuses it on the 5 percent. Now we’re not cooperating. We’re fighting.”
To see the IAFF/IAFC statement in its entirety, visit iafc.org/displayindustryarticle.cfm?articlenbr=40957.
