Calif. county shakes up emergency response system to get to patients faster

Shorter response times and better patient outcomes are the goals of what officials are calling a high-performance, integrated response system

By Ken Carlson
The Modesto Bee

STANISLAUS COUNTY, Calif. — Stanislaus County will seek competitive proposals from ambulance providers for the county’s exclusive response zones, and that could change the landscape of emergency medical response for years.

The ambulance company with the winning bid will be expected to partner with city and rural fire departments, which often arrive at the scenes of medical emergencies and start treatment for patients before an ambulance arrives.

Shorter response times and better patient outcomes are the goals of what officials are calling a high-performance, integrated response system, which places more emphasis on fire-service contributions and is similar to systems in San Mateo, Santa Barbara and other counties. The selected ambulance company will be expected to provide no-cost clinical training to fire agency personnel.

And the fire agencies will receive some dollars for first responder service.

County leaders decided three years ago to develop a more effective and sustainable EMS system. Last year, a one-year extension of five-year agreements with ground ambulance providers was approved to prepare for seeking proposals and the existing contracts were extended again to Oct. 31.

The Mountain-Valley Emergency Medical Services Agency, which regulates ambulance service in the county, expects to release a request for proposals this month and new agreements with ambulance providers will begin Jan. 1, 2020.

The competition could shake up the ambulance business, as American Medical Response for years has been the ambulance provider in the exclusive zones of Modesto-Salida-Empire, Ceres-Keyes and Turlock-Denair. Last year, talks with AMR reached an impasse over what the company said were unfair penalties for not meeting response time standards in the 2013 agreement.

AMR said it wasn’t told until the final year of the five-year agreement the exclusive zones would be opened for competitive proposals from other companies.

AMR Spokesman Jason Sorrick said Wednesday the company will review the county’s formal “RFP” when it’s released and decide whether to compete for the new contract. The company had some concerns after seeing a draft of the county’s request for contractors.

“There was no requirement that the selected bidder honor their current labor agreement” with employees, Sorrick said. The Sacramento-based spokesman suggested a competitor could low-ball the contract and then pay below-standard salaries and benefits to employees hired to serve the zones. If that were to happen, experienced paramedics and emergency medical technicians would leave the county for better pay, Sorrick said, noting there are 200 AMR employees in Stanislaus County.

If AMR is not awarded the contract, the new contractor will need employees to serve the areas, and displaced AMR staff would consider going to work for the new contractor, which may not match the pay and benefits of AMR. With paramedics in short supply nationwide, there are job opportunities elsewhere.

“It happened in Alameda County,” Sorrick said. “What we read in the draft is that the provider pay reasonable wages and maintain the seniority of employees. AMR is one of the higher-paid workforces in that area and one of the few unionized employers there. We operate on a more expensive level than the non-union providers that may bid on these contracts.”

The county’s proposal for a more integrated system recognizes and seeks to strengthen the role of 16 fire agencies in the county. Most all of those agencies have firefighters trained as emergency medical technicians, whose scope of abilities has expanded.

Today, EMTs are trained in initial life-saving measures for people in cardiac arrest. They can administer Narcan to save a person from a drug overdose, provide other medication or insert an airway tube to maintain breathing.

Modesto Fire Department, which has more than 17,000 EMS calls a year, only hires EMT-certified firefighters and has paramedics on three engine companies, Chief Alan Ernst said this week.

“It seems to recognize the value of EMS response that fire departments have provided for years,” Ernst said of the county’s new system. “We deal mostly with AMR and have a good relationship. At the end of the day, we will be working with the provider that comes out of the process.”

According to a county report, a system more integrated with fire service also recognizes that ambulance crews delivering patients are delayed at crowded hospitals and companies may have a difficult time staffing all units with paramedics.

Mountain-Valley, which regulates service in five exclusive zones and three non-exclusive areas, has agreements with ambulance providers including AMR, Oak Valley Hospital District, ProTransport-1, Patterson District Ambulance and Westside District Ambulance in Newman.

The city of Hughson, now in a nonexclusive zone, could be placed in a new exclusive operation area following a hearing Feb. 26.

Exclusive zones, in which one ambulance company serves the area, are meant to avoid confusion and crass competition for patients. Because of their association with special health care districts, the Oak Valley, Patterson and Westside ambulance services won’t be part of the competitive process.

County supervisors gave the green light Tuesday for seeking proposals for exclusive zones.

Supervisor Jim DeMartini said his only concern is that smaller rural fire districts not spend time and resources responding to calls for minor injuries. Some rural districts operate on a shoestring and too many EMS calls would wear out their equipment.

Mike Passalaqua, chief of Woodland Avenue Fire Department, said 70 percent of the rural agency’s responses are medical-related calls. With the county’s new system, Woodland will spend more time at the scene and take on another role of deciding if Code 3 ambulance responses (lights and sirens) are changed to a less urgent response, possibly with the help of a dispatch center triage nurse.

The volunteer department has a nurse and staff trained as paramedics and EMTs, the chief said.

The new program will place an emphasis on training for firefighters using a manikin that’s able to shed tears and register a blood pressure. The ambulance company chosen for exclusive zones will participate with the Mountain-Valley agency in a mobile training unit.

Fire departments entering a partnership agreement with an ambulance provider in an exclusive area will agree to: respond to life-threatening emergencies such as heart attacks or critical injuries; assess patients and begin treatment in the field; file electronic reports and commit to quality improvement.

For Code 3 calls, fire crews involved in private-public partnerships will be expected to arrive at the scene in 7 minutes. The plan sets a standard of 12 minutes for an advanced life-support ambulance in a partnership and 8 minutes for an ambulance without a private-public accord.

Fire agencies won’t rake in big bucks from the arrangements. As compensation for fire departments, the county has proposed minimums of $24 for life-threatening emergencies and $13 to $17 for lower-level EMS calls. An estimated total of $700,000 could be paid to fire departments in the county annually. The source of the funds will be insurance or patient reimbursements to the ambulance provider; it won’t come from local taxpayers.

A recent assessment of ambulance providers, by Mountain Valley and the county, revealed the financial challenges faced by ambulance providers. In 2016, Medicare, at 38 percent, and Medi-Cal, at 35 percent, were the most common source of payments for AMR, while private insurance represented 20 percent. Medi-Cal was almost 40 percent of the payor mix for Patterson District Ambulance.

Since approval of the Affordable Care Act, a large increase in people with Medicaid, called Medi-Cal in California, has created financial stress for ambulance providers because the payments of around $130 per transport cover 25 percent of costs or less. Medicare payments are also below costs for ambulance service, the industry says, and patients with high-deductible health plans struggle to pay out of pocket when responsible for an ambulance service bill.

“You can expand Medi-Cal (eligibility), but the program doesn’t pay the providers for services,” Sorrick said. “The actual costs of a transport are paid by only 20 percent of patients charged for services.”

In bidding to serve an exclusive zone, ambulance providers like Paramedics Plus, Falck USA and AMR identify transport costs, how much they bill for services, unit hours, how dispatch is managed, communications software, use of heart monitors and other things the companies promise to bring to the EMS system.

The county reviews the proposals and then decides which contractor will deliver the best services at a reasonable cost.

Copyright 2019 The Modesto Bee

McClatchy-Tribune News Service

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