Fire chief uses private, public partnership for EMS

Contra Costa Fire Protection District chose to partner with AMR for EMS services over investing in EMS ownership

Like many fire departments, Contra Costa County Fire Protection District, which serves a 300-square-mile area east of San Francisco, was hit hard by the recession. With decreased property values and tax revenue, the county board of supervisors opted in 2012 to close several fire stations and reduce staffing at others.

When Chief Jeff Carman took the reins in 2013, newly arrived from the Sacramento area, he needed to find ways to add capacity to his system without additional resources. The majority of the department's calls were EMS, although at 66 percent, not as high as many other departments in the country.

Carman needed his engines and trucks available to respond to fires, but didn't feel he could just stop sending units to medical calls.

"We never knew where the ambulance was coming from or how long it would be before they could get to a call," Carman said. Because of that uncertainty, the department sent an engine or truck — often staffed with at least one paramedic and several EMTs — to every incident.

At the same time, the department enjoyed a good, but not necessarily close, relationship with AMR Contra Costa, the private ambulance agency that had provided EMS services in the district for decades. During day-to-day operations AMR's EMTs and paramedics worked well with fire department responders. But with separate training programs, dispatch centers and medical directors, coordination was far from optimal.

With the ambulance contract up for renewal, Carman and his team thought they might have an opportunity to make a major change to the way EMS is delivered in the county. They had several options, including bidding on the contract and taking over transport services.

EMS options
The department had firefighters certified as EMTs and paramedics, a training program, a medical director. But it didn't have the ambulances or the extra staffing, both of which would require significant investments that just weren't available.

Instead, the department tried a different route, one that it hadn't been done before. It would bid to provide EMS services, but subcontract with an ambulance service. Two companies expressed interest and the department chose AMR.

"What made sense to me was that AMR has been doing business in the county for 30 years, and they've been doing it well," Carman said.

Almost immediately after creating the alliance — even before the contract was awarded — the fire department and AMR began to build a more efficient and effective operation.

AMR brought its expertise in writing proposals to the table, working closely with the department to respond to the RFP. AMR's design team is also assisting with the creation of new logos and a new look for the ambulances, which will be marked with the Contra Costa County Fire Protection District name.

The two organizations will also unite their medical oversight, with one medical director overseeing the paramedics and EMTs from both the department and AMR, training staff from both organizations under a single roof.

"We've always enjoyed a strong relationship in this county with the fire service, although it was operationally disconnected, just because of two separate structures," said Tom Wagner, CEO of AMR's West Region.

Merged dispatch
Nowhere was that more apparent than the dispatch operations. The department and AMR Contra Costa each had its own communications center. Calls for medical emergencies answered at the county 911 communications center were routed to the fire department's communications center, where call-takers would gather information and dispatch a fire engine.

The incident would then be sent to AMR's dispatch center, which would send an ambulance. But the two dispatch centers had no way of knowing where units from the other agency were located or when they might arrive on the scene.

"If anything changes on the call such as type of call, number of units needed, or specifics on the incident, the CCCFPD fire dispatcher needs to call the AMR dispatch center to relay the change and make sure that they received the information," said Capt. Will Pigeon, who manages the department's communications center.

One of the first steps of the new partnership will be to consolidate the communications centers, which will allow for a more efficient as well as a safer and more effective operation. The AMR dispatchers will now sit in the same room as the fire department call-takers and dispatchers. Units in the field will use the same computer and radio systems.

"Putting our dispatch centers together just makes so much sense," Carman said. "[The AMR ambulances] are finally going to be on our CAD; we're going to look at the AVL and see the ambulances on our map."

Financial risks
The joint venture does not come without risk — in this case, the shift of financial risk from AMR to the fire district. As the organization responsible for ambulance service to the district, the fire department will take over billing for ambulance transport; AMR will receive a set payment for its services that is not linked to the amount collected from patients and their insurers.

This aspect of the alliance caused some concern among county officials, which grew after a consultant told the county board of supervisors that the income from billing for ambulance services might not be as high as they had hoped.

One impetus for the department taking over ambulance service in the district is the Ground Emergency Medical Transport supplemental reimbursement program in California, which was approved by the U.S. Centers for Medicare and Medicaid Services in 2013.

GEMT allows ambulance transport providers to submit for supplemental payments to cover the difference between what they charge and what Medi-Cal, the California Medicaid program, pays. The program is only open to eligible government entities, however —meaning AMR cannot participate.

The question, though, is just how much money will actually become available to the fire district once it starts billing for ambulance transports and, potentially, recouping some GEMT funds. The district believes it will be a substantial amount, but it isn't making any guarantees.

"Even though we believe that there's going to be several [more] million dollars of revenue for us, the proposal we went in with showed less than $2 million annually," Carman said.

Board on board
A consultant hired by the county commended the department and AMR for using conservative estimates in its projections, but also told the board of supervisors that the GEMT money was not a sure thing — and that the new arrangement did not come without any risk.

"Bold leadership is always risky, number one," said Supervisor Mary Piepho. "Number two, AMR has been a very qualified, consistent community partner with Contra Costa County for decades. From my perspective, the continuity in emergency medical response, it takes some of the fear out of taking that risk."

Piepho's board colleague, Candace Andersen, agreed.

"That was one of our primary concerns. If we do not receive the revenue that we anticipate receiving, our taxpayers will be paying the shortfall," she said. But she also cited the proposal's numbers and AMR's long relationship with the community as helping alleviate any of those fears.

Andersen also cited AMR's long presence in the community as an asset to the newly formed alliance, and a reason why Contra Costa County is pursuing this option instead of a total takeover of ambulance service by the fire department as other cities and counties have done.

"For us to jump into that business and all the capital costs made me a little more nervous just because we didn't have the experience," Andersen said. "Do I think we could do it? Yes, if we hired the right people. In this case there seemed to be less of a risk because we worked with AMR."

AMR and the department are finalizing the details of the agreement, with plans for the new contract to take effect in January. Because AMR and the department already work together every day, one thing that won't change very much at all is the care that county residents and visitors receive in the field.

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