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CITY OF SAN BERNARDINO - REQUEST FOR COUNCIL ACTION
From: Shauna Clark
City Administrator
Subject: EMS Transport Feasibility Study
Dept:
G,ilc1IiVAL
Date: September 30, 1996
, '
Synopsis of Previous Council action:
RECOMMENDED HOTIONS:
1. Direct the City Administrator to retain Jim Page to develop a business plan
and to oversee implementation of EMS transport;
2. Under the provisions of Resolution No. 95-136, section I, Term, direct the
Mayor to notify American Medical Response (AMR) that the MOU with Courtesy
Services to provide ambulance transport will terminate May 1, 1997;
3. Establish an EMS enterprise fund and instruct the Director of Finance to
separately account for all EMS revenues and expenditures;,
4. Instruct the Director of Finance to research alternative methods for
financing $1,450,000 in EMS start up costs and additional costs related to
a CADSjRMS upgrade for EMS business analysis, and report back to the Council
on financing alternatives;
5,
Instruct the Director of MIS to work
systems and hardware support necessary
associated with EMS transport.
with Jim Page to determine software
for CADS to run the business analysis
~~
Contact person: Shauna Clark
Phone:
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Supporting data attached:
yes
Ward:
FUNDING REQUIREMENTS:
A t $1,450,000
moun:
Source: IAcct. No.) funding source to be determined
(Acct. DescriPtion)
Finance:
Council Notes:
Res 96- 3/;;..
IO/1/Qr,
Agenda Item No:l ()
75-0262
STAFF REPORT
Emergency Care Information Center (ECIC) has just completed its EMS
transport feasibility study which concludes that a city-operated
ambulance service could be run successfully by the Fire Department
if certain challenges are identified and addressed.
It is not the purpose of this staff report to restate the analysis
provided in the study. This staff report will highlight the issues
that should be considered by the Mayor and Council and recommend
steps toward implementation.
INITIAL INVESTMENT HEEDED
The ECIC report indicates that ambulance transport would allow for
cost recovery that would in time help alleviate pressure on the
General Fund. However, an initial investment of $1,450,000 would
be needed for start-up costs. This money would be expended well
before the first patient is transported, as it is estimated that
the start-up phase could take one year.
Included in this report is a motion that will instruct the Director
of Finance to report back to the council with funding proposals.
The source must be able to provide these funds immediately and to
"float" the payback from future revenues for at least five years.
(A more detailed report on financial issues is attached in the form
of a memo from Barbara Pachon, Director of Finance)
PROPOSITION 218
The study briefly addresses the issue of Proposition 218, the
"Right to Vote on Taxes" initiative that will be considered by
California voters in November.
Subsection (b) (5) of Section 6 of Section 4 of the proposed
initiative states:
"No fee or charge may be imposed for general government
services including, but not limited to, police, fire,
ambulance, or library services where the service is
available to the public at large in substantially the
same manner as it is to property owners."
Language in the initiative is quite ambiguous and it appears that
the word "fee" is the key to interpreting its impact on our ability
to levy a fee for transport. Marianne O'Malley of the State
Legislative Analyst's Office has interpreted the above language to
prohibit any police or fire related fees which would include our
current EMS fees. However, Dennis Barlow, Assistant city
Attorney, points out that language in the definition section of the
initiative associates the word "fee" with property-related fees,
rather than fees for service. Additionally, Dan Terry, President
of the California Professional Firefighters Association and
Treasurer of "No on 218", does not view the above language as a
threat to city-provided EMS transport.
Nevertheless, the final impact of Prop 218 (if passed) is unknown.
LIMITATIONS OF THE CAD SYSTEM
The ECIC report details the problems with the existing CAD system,
and its inability to support the type of advanced analysis that
would be necessary to run a successful EMS transport business. The
report clearly states that more sophisticated hardware and software
are absolutely essential. The costs for this equipment, however,
are not included in the financial projections and are not known at
this time.
In order to fund these purchases, the amount of cost recovery (and
therefore benefit to the General Fund) would need to be reduced.
Other alternatives would be to add a surcharge to ambulance rates
until the equipment is fully funded, or to borrow the money as part
of the start up and to extend the payback period.
MIS is in the process of upgrading CAD/RMS, however there has been
no consideration for the type of hardware and software that might
be needed for the business analysis associated with EMS transport.
The staff report includes a motion that MIS be directed to work
with Jim Page to evaluate the proposed purchase and to recommend
modifications and/or additions as needed.
IMPACTS OF MANAGED CARE
The impact of managed care on the future of the emergency medical
transport industry has been explained to the Council by the current
ambulance service provider, American Medical Response (AMR). The
ECIC report confirms that managed care will have a tremendous
impact on the way all health care services, including EMS services,
are provided in the future.
Any analysis can determine the success of an operation on the basis
of the current environment, however, the continued success of an
operation becomes harder to predict as we move farther along the
planning horizon. The ECIC report details at length the challenges
and opportunities that managed care would provide for a city
ambulance service. A few of particular note are highlighted here.
TransDorts Out of the citv
The ECIC report states the following:
"Any proposal to provide medical transportation must
contain provisions for specialty care services and a
willingness to transport managed care members to any
location within the region."
Under the current system,
ambulance bill even if the
organization's own hospital.
managed
patient
In the
care organizations pay the
is not transported to that
future, that will not be the
-2-
case. The Council should be aware that in order
service to remain competitive, ambulances
Firefighter/Paramedics staffing them will be likely
city on a regular basis to transport patients.
for the city
and the
to leave the
Pathway Manaaement and the 911 System
Managed care organizations are positioning themselves to implement
pathway management (gate keeping or access management). The
development of pathway management systems will be either an
opportunity or a threat to a city-run ambulance service. The long
term viability of city EMS transport will depend on the speed in
which pathway management comes about and our ability to partner
with managed care organizations.
CUrrently the 911 system guarantees a customer base as it is the
only pathway into EMS, and it is controlled by the city. If in the
future the City is able to enter into agreements with managed care
providers and facilitate pathway management for these
organizations' patients in return for a fee, this new development
would present an opportunity.
However, organizations like Kaiser and Health Net may choose, for
a variety of reasons, to divert their patients out of the 911
system entirely by instituting alternative pathway management
systems. It may be, as some have stated, too expensive and
complicated for these organizations to enter into pathway
management agreements with every city and county that operates a
911 system. Instead, managed care organizations may contract
individually for independent services, or join together to form a
system separate from 911.
Many experts feel that managed care is heading in the latter
direction. If that is the case, the city's insured customer base
for ambulance service could erode dramatically, leaving the city
with only the uninsured and indigent patients and limited fees to
support services.
OPERATING AS AN ENTERPRISE FUND
Because it must operate as a business, the ambulance service
finances would be set up in a separate fund. Like all businesses,
a city ambulance service would place the city in some financial
risk. In addition, it may be that in the future cost recovery
projected to benefit the General Fund may instead be used in
investments necessary to keep the business viable.
For those reasons, this staff report includes a motion to establish
an EMS enterprise fund.
CONCLUSION
Based on the current environment, the competency of Jim Page, and
the analysis performed by ECIC, I support city-run EMS transport.
However, each of the above issues must be fully addressed and
resolved before we transport our first customer. I feel it is
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necessary to retain Jim Page for as long as possible to get this
program running successfully.
I also believe that once we begin transport it would be difficult
to eliminate it. The residents of San Bernardino would have become
accustomed to this, in much the same way that residents expect
paramedic services. However, if it becomes apparent that city-run
EMS transport does not have long term financial viability, I will
recommend returning the service to private.
RECOMMENDED MOTXONS:
1. Direct the city Administrator to retain Jim Page to develop a
business plan and to oversee implementation of EMS transport;
2. Under the provisions of Resolution No. 95-136, Section I,
Term, direct the Mayor to notify American Medical Response
(AMR) that the MOU with courtesy Services to provide ambulance
transport will terminate May 1, 1997;
3.
Establish an EMS enterprise fund
Finance to separately account
expenditures;
and instruct the Director of
for all EMS revenues and
4. Instruct the Director of Finance to research al ternati ve
methods for financing $1,450,000 in EMS start up costs and
additional costs related to a CADSjRMS upgrade for EMS
business analysis, and report back to the Council on financing
alternatives;
5. Instruct the Director of MIS to work with Jim Page to
determine software systems and hardware support necessary for
CADS to run the business analysis associated with EMS
transport.
-4-
.',
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CITY OF SAN BERNARDINO
INTEROFFICE MEMORANDUM
FINANCE DEPARTMENT
TO:
Shauna Clark, Ci'y Admini.'ra'or ,,() , ~"
Barbara Pachon, Director of Finance~ttt
FROM:
SUBJECT:
ECIC REVENUE << EXPENSE MODELS FOR EMERGENCY MEDICAL
TRANSPORTATION SERVICES
DATE:
September 25, 1996
COPIES:
Will Wright, Fire Chief; Fred Wilson, Assistant City
Administrator; Lori Sassoon, Administrative Analyst
During the City's meeting with Ty Mayfield of ECIC on September 12,
and in subsequent phone conversations between Ty and Rita West of
the Finance Department during the week of September 16, a number of
issues were clarified, Outlined below are the key points
discussed:
1. ECIC defines the revenue numbers they have calculated as "the
default position for exact cost recovery," According to Ty,
the total revenue figure of $4,030,360 represents the "minimum
amount of revenue that the City can expect to receive"
assuming that the collection ratios hold true, Ty based his
projections on the assumption that the City will charge the
maximum rate allowed by ICEMA for the ALS All-Inclusive Rate
($622,10) ,
The expense model identifies new costs only; it does not shift
any existing Fire Department costs related to EMS into this
model.
2. Assuming that the City will charge the maximum All-Inclusive
Rate allowed by ICEMA, the next issue raised was where is the
benefit to the customer if the City is charging the maximum
allowed, Ty pointed out two areas where the customer will
benefit:
a. Not included in the revenue projections are first
responder charges, night surcharges, weekend charges, and
unscheduled response/emergency charges. All of these
fees are currently charged to patients by the City's
current provider of emergency medical transportation
services.
b. Currently, patients are charged first responder (EMS
fees) by the Fire Department, and the ambulance company,
If emergency transportation is provided by the City,
patients would not be "double-billed" as is now
perceived,
(page 1 of 3)
,I
3. In reviewing the revenue and expense models, it appeared that
the net gain to the City was $423,835 (the difference between
$4,030,360 in projected revenue and $3,606,525 in projected
expenses), The City already budgets approximately $360)000
annually in EMS revenue, so the final net gain appeared to be
only $63,835, It was unclear what the benefit was to the
General Fund. Ty addressed the following as benefits to the
General Fund:
a. The expense projections include a $480,830 charge for
overhead; this charge would be a payment to the General
Fund.
b. The City could decide to continue to charge :t:irst
responder fees (the $100 BLS fee and $200 ALS fee
currently charged by the Fire Department); in this case,
the $360,000 currently budgeted would be revenue in
addition to the $4,030,360 projected by ECIC.
c. Although ECIC has indicated that the maintenance and
operation costs in the expense model are for new expenses
only (not a shift of existing expenses), they have
indicated that there possibly may be some additional
savings to the General Fund in the area of fuel and
lubricants because vehicles which are solely Fire related
would roll on fewer calls and the EMS vehicles would pick
up these calls; however this savings is unknown and
cannot be quantified at this time,
After discussing the revenue and expense models with Ty Mayfield,
the following points were identified as issues that the City needs
to resolve, These are issues which the consultant has stated are
policy decisions that the City needs to address:
1, Rates still need to be addressed, ECIC is not stating what
rate the City should charge, They based their revenue model
on the maximum ALS All-Inclusive Rate allowed by ICEMA, The
City could choose to have first responder fees, night
surcharges, etc, The City could also choose to charge less
then the maximum allowed by ICEMA. Additionally, the City may
not be confined to ICEMA's rates; it appears that legal
clarification might be necessary on the issue of ICEMA's
authority over the City.
2. A method of financing start-up costs needs to be identified.
The revenue and expense models discussed above address revenue
and expense proj ections for year one; however, ECIC has
estimated that before revenue is generated, the City will have
a start-up cost of $1,450,432, ECIC has suggested the EMS
Fund borrow from another fund and then repay the loan by
adding a surcharge to bills over a five year period. It is
questionable whether or not a surcharge could legally be added
to some patients bills and not others, especially in light of
the growing movement that a city's fees should tie directly to
a city's costs.
(page 2 of 3)
3. Public entities are not supposed to make profits charging fees
for services; a method for shifting existing EMS costs into
the EMS fund has to be established in order to correctly match
all costs with all revenues. ECIC's expense model only
identifies new expenses, it does not identify existing costs
which should be shifted to the EMS fund,
4. The effect of Proposition 218, the "Right to Vote on Taxes
Initiative," on a City operated ambulance service needs to be
addressed, In the opinion of Marianne O'Malley of the State
Legislative Analyst's Office, one specification of the
proposition "is that no fee can be charged for fire, police,
ambulance, library, or any other service widely available to
the public," If this opinion is correct, not only would the
City be prohibited from charging for ambulance services, the
City would also have to stop charging for the EMS fees that
are currently in effect. This requires legal clarification,
5. Specific policies and procedures need to be ~stablished
regarding the following: criteria for determining charges,
methods to resolve disputed charges, collection of fees,
insurance billing, Medicare and Medi-Cal billing, handling of
delinquent accounts, and write-off of charges,
Please let me know if you have any questions or wish to discuss
this further,
(page 3 of 3)
The Feasibility of
Fire Department-based
Emergency Medical Transportation
within the
City of San Bernardino
Submitted by:
Emergency Care Information Center
Carlsbad, California
September 1996
City of San Bernardino
September 1996
Table of Contents
INTRODUCTION ............................................................ 1
SIGNIFICANT FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
RESPONSE TIME PERFORMANCE .............................................. 2
SERVICE DEMAND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
IMPACT ON FIRE SUPPRESSION CAPABILITY .....................................3
App ARA TUS, EQUIPMENT, AND FACILITIES ...................................... 3
DISPATCH AND COMMUNICATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
EDUCATION AND TRAINING ..................................................5
QUALITY MANAGEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
STAFFING AND SUPERVISION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
DEPLOYMENT ............................................................. 9
WORK FORCE ISSUES ...................................................... 10
EQUAL OPPORTUNITY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
TURNOVER AND BURNOUT .................................................. 11
PUBLIC INFORMATION, EDUCATION AND RELATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
SHORT TERM OBSTACLES TO IMPLEMENTATION ............................... .12
LEGISLATIVE....................................................... .12
PERSONNEL TRAINING ................................................ 12
DEPLOYMENT PLAN AND RESPONSE TIME PERFORMANCE ..................... 12
LABOR ISSUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
OFFICE AUTOMATION AND INFORMATION MANAGEMENT ..................... 13
IMPLEMENTATION OF SYSTEMS FOR CLINICAL AND OPERATIONAL ACCOUNTABILITY 14
Emergency Care Information Center
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City of San Bernardino September 1996
MEDICAREIMEDICAIDPROVlDERELIGIBILITY ..............................14
LONG TERM OBSTACLES TO IMPLEMENTATION ................................. 15
MANAGED CARE IMPACT/HEALTH CARE REFORM .......................... .15
CONTINUED ORGANIZATIONAL COMMITMENT TO EMS DELIVERY. . . . . . . . . . . . . . . 17
COMPLIANCE WITH PERFORMANCE REQUIREMENTS ......................... 17
CAREER PATH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
RESPONSIVENESS TO CUSTOMERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
The First Opportunity: Public Education ........................... 19
The Second Opportunity: Communications. . . . . . . . . . . . . . . . . . . . . . . . . . 19
The Third Opportunity: First Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
The Fourth Opportunity: Mobile Medical Services and Transportation. . . . 20
COST RECOVERY/ FINANCIAL EFFICIENCY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 21
IMPACT ON THE GENERAL FUND .............................................22
REVENUE PROJECTIONS ............................................... 22
EXPENSE PROJECTIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
PERSONNEL, EQUIPMENT, AND ADMINISTRATIVE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
LIABILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
ApPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
CALL VOLUME. .... . ... ... .. .. .. ... .......... ... . ......... ..........29
FINANCIAL ......................................................... 33
Emergency Care Information Center
Page ii
City of San Bernardino
September 1996
INTRODUCTION
This report is the third EMS-related project completed by Emergency Care Information
Center on behalf of the City of San Bernardino. The two earlier projects were a system
design and quality management review conducted by Jim Page in July 1992 and an
operational feasibility study performed by ECIC staff in January 1993. This report is a
follow up to the 1993 feasibility study to update the quantitative aspects of the previous study
and to discuss changes in the health care and business environments.
SIGNIFICANT FINDINGS
1. There is sufficient capacity and capability within the fire department to operate an
emergency ambulance transport program. The firefighters' union is supportive of the
efforts of the City to explore upgrading its EMS capability.
2 Dispatch and communications is a significant obstacle to successful operation of a
transport program. The CAD (hardware and software) is inadequate to perform to
current industry standards. A proposed merger of police and fire dispatch functions
would limit the ability of the fire department to capitalize on communications
opportunities.
3. EMS quality management activities in the department must be upgraded and
expanded to compete in a dynamic market place. Quality management should be
designed to provide internal assessment and external scanning to identify
opportunities and threats.
4. Additional administrative and support staff dedicated to the EMS Division will be
needed to properly and adequately manage fire department EMS resources. A strong
program director is the key to building a successful team.
5. Managed care will have a significant impact on the way EMS agencies conduct
business. There are four clearly defmed business opportunities for EMS providers in
the managed care environment: public education, communications, first response, and
transportation.
6. Elected and appointed city officials must provide continued support for the business
efforts of the fire department as it adjusts and adapts to rapidly changing market
forces. This is not a static model and all components must have the ability to function
at maximum effectiveness and efficiency over an extended period oftirne.
7. The proposed transport program is designed to operate at cost-recovery under all
operational scenarios. The start up period could vary from six to 18 months. Payback
of start up costs will depend on the financial preferences of the City Council. The
revenue stream will not be fully established until three to six months after transport
Emergency Care Information Center
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City of San Bernardino
September 1996
begins. Depending on business decisions made by the City, there could be noticeable
savings to the General Fund.
RESPONSE TIME PERFORMANCE
In our 1993 feasibility study, we estimated first response engines to have response time
intervals of three to five minutes in their primary response zone. Paramedic engines were
estimated to have a response time interval ofless than six minutes to all parts of the City.
When a paramedic engine is responding in its primary response zone, its response time
performance would be equal to first responder engines. The initial report also indicated the
private ambulance would arrive at the scene of a medical emergency in ten minutes or less.
The deployment of six ambulances proposed by the union would most likely provide
response time intervals equal to those experienced by paramedic engine companies (six
minutes or less).
At the beginning of the project, we requested current raw dispatch data from the City's
computer assisted dispatch system. On May 9th, we were notified that the data was being
collected. Subsequently, we learned that raw data containing the information necessary for
quantitative analysis could not be extracted from the computer. There is no information
available that would indicate the response time intervals identified in the earlier report are no
longer valid, therefore, this report will use those same intervals as appropriate indicators of
EMS response time performance in San Bernardino.
SERVICE DEMAND
Service demand is based on an analysis of historical data, population changes in the City, and
quantitative methods to create multiple forecasts of future demand for services. Since 1987,
the number of EMS responses made by the fue department has increased an average of 3.5
percent per year. In that same period, the population of San Bernardino has grown by nearly
78,000 people or an average increase of 5.1 percent per year.
Using linear regression, we created two forecasts of future service demand. The more
conservative forecast has an average armual increase in call volume of 0.9 percent. This is
one-fourth the historical average armual increase. This forecast is the basis for all financial
and resource calculations used in the current report.
The more optimistic forecast has an average armual increase in call volume of 3.1 percent.
This is nearly the same as the historical changes. However, because business environmental
factors are changing so rapidly, this forecast presents armual call volumes that may not
materialize.
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Emergency Care Information Center
City of San Bernardino
September 1996
The measure of productivity used in emergency medical services is the "unit hour utilization"
(UHU) rate. UHU is a measurement of how hard and how effectively the system is working.
It is calculated by dividing the number of responses (or transports) initiated during a given
period of time by the number of unit hours produced during the same period of time. (1 unit
on duty 24 hours with 10 responses = 10/ (1*24) = 0.42 UHU) In the current analysis, this
rate was used to determine whether the proposed resource deployment would be adequate to
meet substantially larger call volumes than identified in the forecast.
Using the conservative service demand forecast, the proposed ambulance configuration
would be operating at a UHU of 0.19 and in the optimistic forecast, the UHU would be 0.25.
To reach the accepted industry maximum UHU of 0.40 would require 10,000 responses per
year beyond the volume calculated in the more optimistic forecast. Thus, the optimistic
forecast has value because it demonstrates the proposed deployment of resources is more than
adequate to meet service demand levels one-third higher than those contained in the more
optimistic forecast without overburdening crews or equipment.
In contrast, should service demand be lower than calculated in the conservative forecast, it
appears that normal departmental attrition would be sufficient to absorb the decreased need
for resources. Reducing call volume 25 percent would eliminate the need for two
ambulances. This personnel could be reassigned to other stations to expand the paramedic
first responder component until natural attrition creates vacancies filled by staff reassigned
from the unneeded ambulances. The unneeded ambulances could be used as supplemental
vehicles during periods of unusually high demand and as reserve vehicles to extend the
overall life of the fleet.
IMPACT ON FIRE SUPPRESSION CAPABILITY
Specific information regarding the occurrence of simultaneous fire and EMS incidents was
not available from the data supplied for this analysis. However, in another California city,
we found the probability of an EMS incident and a multi-alarm fire occurring within the
same 60 minute interval in the same primary response zone was three per 10,000 incidents.
Independent research conducted by ECIC staff indicates an average EMS response takes
approximately 20 minutes from the time the engine is dispatched until the engine company is
available for the next response. The same research project indicates a fire response takes
approximately 40 minutes. Combining the rarity of EMS and multi-alarm fires occurring in
the same 60 minute interval, the very low probability of these events occurring in the same
primary response zone, and the short time period resources are committed to a particular
incident make the probability of all conditions converging simultaneously extremely small.
App ARA TUS, EQUIPMENT, AND FACILITIES
The department has eleven engines in the active fleet, however, seven have over 100,000
miles. Vehicles are inspected daily by the engineer and logged on the Daily Apparatus
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Emergency Care Information Center
City of San Bernardino
September 1996
Checklist. Each month the logs are forwarded to the shop supervisor and Battalion Chief for
review. Any deficiencies identified on the daily check are prioritized according to its impact
on safety and the workload in the shop. Fleet management record keeping is done manually,
rather than with the computerized system used by other city fleets.
Preventive maintenance is performed twice per year for heavy apparatus and every 2,000
miles for light vehicles. Should the department include ambulances in the fleet, the
preventive maintenance schedule is expected to be at 4,500 mile intervals. The shop has four
bays with heavy lifts and six bays without lifts. An out-of-service fire station at the site is
used for storage and additional work areas. Once the two vacant mechanic positions are
filled, the existing fleet management personnel and facilities could absorb eight additional
vehicles into the existing system without difficulty.
The biomedical and patient care equipment used by the fire department reflects the current
state-of-the-art and is maintained according to department and manufacturer's standards.
The department's existing facilities are adequate for expanded EMS service. Each station
meets OSHA requirements and can provide indoor parking for the ambulance fleet with little
or no redistribution of reserve apparatus. The stations have been remodeled or reorganized to
meet the privacy needs of a male and female workforce.
DISPATCH AND COMMUNICATIONS
The emergency dispatching process starts with the 911 operator who transfers fire and
rnedical calls to the fire dispatcher. The telephone person gathers the initial information and
relays the information to the radio dispatcher who broadcasts the alarm to the stations and the
crews in the field. The telephone person provides pre-arrival instructions to the caller, while
the radio person keeps track of vehicles and crew status. Pre-arrival instructions have been
used since 1994 and are adapted from the protocols used in Orange County. A very limited
call prioritization program has been in place since Spring 1996. Call prioritization identifies
two categories, life-threatening and non-life-threatening. The determination of non-life-
threatening is made when the affected body part is below the elbow or below the knee.
Both of these dispatch programs have been limited by ICEMA. The limited capability of call
prioritization and pre-arrival instruction will negate the City's ability to capitalize on
business opportunities associated with EMS communications. This is significant because to
be successful, an EMS organization must be able to create, develop, modify, and improve all
system components related to service delivery.
Another significant limiting factor is the computer assisted dispatch (CAD) hardware and
software. The existing CAD carmot support more detailed medical protocols or more
dynamic resource management methods. The current equipment is approximately twenty
years old, is no longer supported by the vendor, and is incapable of delivering data or
generating reports useful for quality management or system performance analysis. Transport
Emergency Care Information Center
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City of San Bernardino
September 1996
is not the only EMS product with value in the managed care environment and service
delivery agencies must be able to adjust and adapt to changing conditions without
unnecessary internal or external barriers.
Although currently co-located, the proposal to combine police and fire/EMS dispatch and
communications would create more difficulties than would be solved. Co-location (both
organizations in the same facility using similar equipment but different protocols) is not a
significant issue and probably creates some savings for the City. Because the training and
operational requirements of police and fire/EMS emergency communications systems are
significantly different, cross training dispatchers in both police and fire/EMS
communications protocols would reduce the efficiency of both organizations.
The training and information-gathering techniques necessary to be effective in one discipline
are noticeably different than the requirements of the other. In addition, using cross-trained
dispatch personnel to implement and manage two different and complex communications
programs would be very difficult. The information gathering and service delivery
requirements in a managed care environment are not compatible with dispatch personnel
cross-trained for police and fire/EMS communications.
EDUCATION AND TRAINING
New employees join the department with their initial training already completed (both
firefighter I certificate and paramedic certification). New employees also receive a two-week
orientation to the job before reporting to their permanent assignment. Paramedics also must
be supervised by a department paramedic for ten advanced life support patient contacts
before they are allowed to work independently.
Currently, EMT firefighters are not included in ongoing departmental continuing education
activities provided to paramedic firefighters. However, there are plans to implement a
monthly integrated continuing education program for both levels of certification. The
department was recently granted an EMS continuing education provider number, which will
allow EMS education programs and classes developed by the department to help meet armual
continuing education requirements of paramedics.
Continuing education activities are exclusively focused on meeting paramedic re-
accreditation needs and do not address topics important to maintaining and improving the
overall EMS program. There is only a limited connection between continuing education and
quality management. The clinical supervisor is doing data entry and analysis at home on
personal time, indicating the computer resources and administrative recognition of this
function are not adequate for optimal organizational performance in a rapidly changing
environment.
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September 1996
QUALITY MANAGEMENT
All efforts in this area are retrospective and are conducted in a marmer which could create a
negative perception among dispatchers and field personnel. Current quality management
techniques focus on "correcting" perceived errors or deviations of individuals after the fact.
Although intended to be educational, these corrections are usually perceived by the worker as
a punitive action imposed by the supervisor.
Each dispatcher has four incidents reviewed each month by the communications supervisor,
who sends a monthly summary report to ICEMA. ICEMA in turn, re-reviews the four
incidents for each dispatcher. Only those incidents that have raised some sort of "red flag"
are likely to be reviewed. As deficiencies or deviations from protocol are identified,
dispatchers are given individual instruction. System-wide trends in dispatcher activities are
not analyzed, but some data is collected that could be useful for analysis.
Several quality management activities are performed for field operations, but only after the
fact (retrospective). The department does not appear to utilize any concurrent or prospective
quality management tools. The only performance standards are local treatment protocols and
some internal procedures. In addition, there appears to be little connection between quality
management, continuing education, communications, and overall operational performance.
However, if resources become available, quality management activities may be used as a
source of training topics.
Each month 30 patient care records (PCRs) (approximately one percent) are reviewed for
completeness, adherence to protocol, and time-at-scene. Deficiencies are investigated and
resolved with the specific crew submitting the PCR. A rnonthly summary narrative report is
prepared and submitted to ICEMA, but the report does not have a standard content or follow
a particular format. There are no quantitative or statistical analyses of field activities.
The EMS oversight agency (ICEMA) likewise uses retrospective review as its only quality
management tool. Also, ICEMA appears to concentrate its quality management activities on
the correction of individual problems. Fortunately, the incidence of events requiring
intervention by ICEMA is relatively low (I every 2 or 3 months). There is also a "Quality
Council" comprised of the EMS provider agencies in the area. The purpose of the council is
to identify common issues and areas of interest for system-wide quality management review
and inquiry. This council seems to be developing the link between quality management and
operational performance on a multi-agency, system-wide basis.
The days of using quality management as a weapon in an attempt to discredit individuals and
agencies appear to be over. Interagency relations appear to be more cordial than they have
been in several years. Issues that previously had been forced into formal investigations are
now more likely to be resolved with informal meetings or phone calls outside official
command structures.
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September 1996
The quality improvement coordinator, like the C.E.U. clinical supervisor, is doing data entry
and analysis at home on personal time, indicating the computer resources and administrative
recognition ofthis function are not adequate for optimal organizational performance in a
rapidly changing environment. To be successful in the rapidly changing health care
environment, an EMS organization must use the internal assessment and external scanning
capabilities of a sophisticated and interconnected quality management program. The
emphasis on correcting individual past mistakes must be replaced with a prospective and
concurrent process-oriented approach. Using quality management to integrate all
components of EMS program activity to identify and capitalize on opportunities appearing in
the marketplace will ensure the agency is successful in meeting its business goals.
STAFFING AND SUPERVISION
The department uses a "constant staffing" configuration to ensure an adequate number of
personnel are available for all on-duty crews. The proposed transport model includes 18 new
firefighter/paramedics plus a constant staffing factor (equal to 3 personnel) to conform to
existing staffing practices. The 18 new personnel would be teamed with existing
firefighter/paramedics to form six combination companies. These combination companies
would include an engine and an ambulance and have five persons rather than the usual three
found in other engine and truck companies.
A fire department-based transport program would require a dedicated administrative staff to
provide oversight and support functions. In order to group similar activities together, an
"EMS Division" could be formed and all BLS and ALS first responder administrative and
support personnel and activities transferred from other parts of the organization.
The EMS Division would be lead by an Assistant or Deputy Chief as the lead administrator.
A Program Director would provide day-to-day management. A Quality Manager would
monitor organizational performance and identify opportunities and threats in the business
environment. An Administrative Analyst would perform quantitative and analytical tasks at
the direction of the Quality Manager and Program Director. A Continuing Education (C.E.)
Director would be responsible for administrative tasks associated with being a C.E. provider
agency and creating and developing community education products. An Education
CoordinatorlLiaison would ensure training requirements were met, organize and monitor
field training activities, and attend meetings as the department's representative to various
stakeholder groups. An Administrative Operations Supervisor would assist the Program
Director and act as office manager for the EMS Division.
Currently, the Medical Director is an existing, volunteer position. To be successful in a
rapidly changing environment, the Medical Director needs to be an active member of the
rnanagement team. To compensate for added responsibilities, the Medical Director would
become a paid position within the administrative structure of the EMS Division. A
reasonable contribution from this person would be an equivalent of one day per week to
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September 1996
monitor all aspects of the program that could have an impact on clinical excellence or patient
outcomes.
The Program Manager is responsible for the development and administration of the
department's EMS program. He/she must conduct and coordinate all long- and short-term
pi arming processes, monitor the daily and weekly activities of the administrative and support
staff, interact with a wide array of constituency groups, and work daily to ensure that the
program receives the necessary financial and administrative support to ensure high quality
EMS remains the objective of the program.
The Quality Manager is responsible for designing the systems that capture operational and
clinical data used to monitor and measure program performance. The Quality Manager also
acts as the management information services (MIS) liaison between the EMS Division and
those responsible for providing input regarding organizational performance. The Quality
Manager also acts the MIS liaison between EMS Division management and the local EMS
agency for operational oversight and clinical performance measures. In addition, the
incumbent assists in the design and coordination of data necessary for ongoing program
activities, accurate fiscal monitoring of the program, and armual budget development. This
will be especially important during the start-up phase of program. The Quality Manager
rnust possess sufficient authority within the management structure to influence department
strategic planning and governance.
The Administrative Analyst will be directed by the Quality Manager to perform a variety of
data collection and analysis tasks. The incumbent will be responsible for collecting,
cleaning/qualifying, and executing programs which will analyze clinical and operational
performance, which will then be evaluated by the Quality Manager. Data analysis will be
conducted using processes and procedures designed by the Quality Manager. In addition, the
Administrative Analyst would be required to prepare both routine and ad hoc reports using
basic statistical calculations. Therefore, the Administrative Analyst should have good
organizational and writing skills.
The Continuing Education (C.E.) Director will monitor and administer all activities related to
state licensure and county accreditation. The incumbent will also design, develop and
execute the department's paramedic and EMT C.E. program. The C.E. Director is
responsible for selection and production of all C.E. materials using a variety of media. The
incumbent also is responsible for design and development of customer input, focus groups,
and data collection designed to explore service delivery needs to aid in the development of
"value-added" services.
The Education CoordinatorlLiaison is responsible for ensuring the paramedic program meets
all requirements for state and local accreditation. The incumbent also is responsible for
monitoring all quality management data relative to clinical skills performance. The
Education CoordinatorlLiaison is responsible for preparing for and attending regularly
scheduled meetings, as well as coordinating subcommittee meetings at the department level
and ad hoc meetings necessary for efficient operation of the department's EMS program. In
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City of San Bernardino
September 1996
addition, the Education CoordinatorlLiaison is responsible for preceptor training and
mediation between preceptors and paramedic students.
The Administrative Operations Supervisor coordinates and manages administrative services
related to the EMS Division. The incumbent analyzes, develops, and implements procedures
for expediting administrative work flow. The Administrative Operations Supervisor
supervises, instructs and evaluates clerical personnel to ensure efficient business office
operations. In addition, the Administrative Operations Supervisor prepares fiscal analyses of
EMS operations, supervises purchase requisitioning and accounts payable, and oversees the
collection and deposit of program revenues from the billing agency.
The Medical Director is the key to establishing and maintaining a high quality EMS program.
He/she insures that systems changes are closely scrutinized to ensure patient care is not
negatively impacted. The Medical Director is responsible for the scientific application and
study of pre hospital care within the context of the EMS program and is responsible for
conveying the science of EMS to system participants to ensure the program remains
medically driven.
Supervision will use existing structures and procedures. The department has a well-
established incident command system (ICS) that can be tailored to the operational and
tactical requirements of any emergency response including medical and disaster incidents.
Skills in concurrent clinical supervision will have to be developed within the department.
Clinical performance needs to be monitored separately from activities associated with
employee supervision and evaluation. There needs to be ongoing supervision for medical
activities in the field and someone to ensure medical priorities are met in larger or combined
incidents.
DEPLOYMENT
The deployment of resources for the proposed transport component is based on an earlier
feasibility study conducted by ECIC in 1993. This deployment, adopted in the union's
proposal, includes six active ambulances and two reserve units. The active ambulances
would be located at stations 1,2,3,4,6, and 10. Stations 5, 7,8,9, and 11 would have
paramedic first responders on the engine companies. The two reserve ambulances would be
available during times of unusually high service demand or when one of the active
ambulances is out of service.
In response to market forces, the fue department should review regularly and perhaps modify
the proposed deployment to maximize efficient use of resources. Possible modifications
include locating ambulances at different stations, staffing some ambulances to be on duty
only during periods of high service demand, decreasing the total number of ambulances in
the fleet, or providing additional medical transportation products.
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City of San Bernardino
September 1996
The personnel deployment would be two truck companies with three person crews, five
paramedic assessment engines with three person crews (one paramedic), and six
engine/ambulance companies each with crews of five persons consisting of a captain,
engineer, firefighterlEMT and two firefighter/paramedics. Paramedics would have a chance
to alternate between the paramedic assessment engine company and the ambulance, creating
greater opportunities to maintain fire suppression and rescue skills. This deployment
improves fire scene safety by reducing the likelihood that an engine company will respond to
an active structure fire with too few personnel.
WORKFORCE ISSUES
When any significant change takes place in an organization there are likely to be questions
from the current labor force. One of the more significant problems other cities have
encountered is the work force does not want to undertake the expanded role. Often, the
change is the chiefs idea and not theirs. This is not the case in San Bernardino. In the
existing public-private system, the lack of teamwork and the inability to take the patient to
the hospital have proven to be frustrating to the majority of fire department paramedics.
Another problem typically encountered with the labor force is failing to involve the rank and
file in the plarming phase. The San Bernardino Professional Firefighters have been studying
the issues related to the development and implementation of ambulance transport capability
by the department. The bargaining group supports the efforts of the City. In addition, Local
891 is willing to work cooperatively with the administration to identify and resolve any
questions related to potential changes in working conditions. The fuefighters recognize long
term success is dependent on providing high quality and high performance EMS services.
A transport program would result in changes to fuefighter/paramedic schedules and working
conditions. The different staffing patterns could include 12-hour shifts and may include
some sort of rotation between engines and ambulances or between busier and slower units.
The implementation of a fire department-based paramedic ambulance program may result in
the displacement of some private ambulance employees. However, we recommend the
department absorb as many displaced private paramedics as possible to minimize any
negative consequences.
EQUAL OPPORTUNITY
The department conforms to City, state and federal guidelines regarding the recruitment,
selection, hiring, and retention of people in protected classifications. There do not appear to
be any issues which could have a negative impact on the development and implementation of
transport capability by the department.
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City of San Bernardino
September 1996
TURNOVER AND BURNOUT
High levels of occupational stress are prevalent within the emergency response environment
and can lead to paramedic "bumout." Occupational stress is frequently cited as one of the
leading causes of job dissatisfaction among paramedics. Dr. John Cox, author of a study of
paramedics and EMTs in the Salt Lake City area, stated the stresses and strains of prehospital
employment "will first demonstrate itself through a variety of seemingly insignificant signs,
such as a growing negative attitude, complaining, broadening hostility, depression, and
diminished job performance.'" Dr. Jeffrey Hanuner further emphasizes "the impact of stress
on performance provides the major reason for concern."2
In addition to concerns regarding job performance, and therefore patient care, job-related
stress can lead to excessively high levels of personnel turnover, subsequently increasing
system costs associated with recruitment and training. There are many factors within the
EMS work environment that can either mitigate or increase stress experienced by prehospital
care providers. Some of those factors include the amount of system misuse or abuse,
hostility of patients, reliability of equipment, and the workload and deployment of system
resources. Each of these factors or job characteristics fall into one of two categories. One
category is outside the control of the provider agency, such as system misuse and levels of
patient hostility. The other category is made up of characteristics controllable by the
provider agency, such as equipment reliability, unit workload, and resource deployment.
A study by ECIC3 found personnel who work in very dynamic system status-managed (SSM)
systems experienced higher levels of job-related stress than their "geo-based" (fire stations)
dual-role, cross-trained counterparts. Interestingly, workload was not a factor. The authors
concluded job characteristics controlled by the EMS provider agency had significantly more
impact on levels of stress than job characteristics not controlled by the EMS provider agency.
PUBLIC INFORMATION, EDUCATION AND RELATIONS
The department has an active public information, education and relations (PIER) program
which includes school programs (adopt-a-school, soap box derby), awareness activities, and
public service armouncements using local electronic media. There are public information
McGlown J: Attrition in the Fire Service, A Report. FEMA, USF A 10, 1981.
2
Hanuner JS, Mathews 11, Lyons JS, et al: "Occupational Stress Within the
Paramedic Profession: An Initial Report of Stress Levels Compared to Hospital
Employees." Annals of Emergency Medicine. 15(5):536-539, 1986.
3
Cady G, Page JO, Scott T: A Comparison of Occupational Stress Differences
Between Fire Department Dual-Role, Cross-Trained EMS Providers and Single-
Role EMS Providers. 1992.
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City of San Bernardino
September 1996
officers (PI Os) assigned to each shift. The department expressed an interest in expanding
PIER activities to more business and community groups.
Customer complaints are rare events usually handled informally by telephone. Most
complaints are because the caller is uneducated about some aspect of fire department activity
and an explanation of the reasons for particular actions is usually sufficient to satisfy the
caller. While there is no designated person for resolving customer complaints, the described
process appears to function well. Complaints are resolved as soon as inquiries to all involved
parties can be completed. When a complaint carmot be resolved immediately, the department
specifies a date and time for follow up with the citizen.
SHORT TERM OBSTACLES TO IMPLEMENT A TION
LEGISLA TlVE
The most significant legal issue is the lawsuit between the City and County of San
Bernardino pending before the California Supreme Court. The case is expected to resolve the
apparent conflict between Health and Safety Code Section 1797.201 and H&S Code Section
1797.224.
Proposition 218, if adopted, could have an impact on the City's ability to operate an
emergency ambulance transport business. However, the language of the initiative does not
adequately define terms or accommodate unique situations and if approved by the electorate
will surely be challenged in the courts.
Legislation in the areas of managed care, scope of practice for field providers and EMS
agencies, and changes in funding sources and mechanisms have been introduced in other
states and may appear in California. The breadth and depth of the legislative language is
impossible to predict, but if a strong and proactive EMS organizational structure is formed in
the department, the department should be able to adjust and adapt to changes in the
environment with little disruption to the program.
PERSONNEL TRAINING
All personnel hired by the department are already certified at the firefighter I level. When
new, additional paramedics are needed, they are already licensed and accredited along with
the firefighter I certificate. There should be little, if any, need for the department to provide
initial firefighter or paramedic training to existing staff or new field employees.
DEPLOYMENT PLAN AND RESPONSE TIME PERFORMANCE
The fixed-location resource deployment of the union proposal means the demand for service
will create uneven workloads among the different stations. Certain regions of the city
historically and statistically have a higher incidence of medical emergencies. On one hand,
those fire stations in or near areas of higher service demand will respond more often. On the
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City of San Bernardino
September 1996
other, all medical resources are available at all times, which means there are resources for
periods of unanticipated very high service demand. However, this creates under-used
available response capacity the rest of the time.
A dynamic resource deployment of ambulances means the demand for service will be
distributed more evenly throughout the workforce. In dynamic deployment, ambulances are
distributed according to the statistical likelihood of a request for service occurring in a certain
area within a given time span. The advantage is the workload is distributed among all units;
the disadvantage is there may not be resources available during periods of unanticipated very
high service demand. This leads to increased productivity, but occasionally longer response
times.
LABOR ISSUES
There were no major labor issues presented by the firefighters bargaining unit. Fire
department staff expressed a strong desire to add transportation under the umbrella of their
current system to "complete the loop" of medical services. Union officials stated they were
well informed by fire department management and appreciated being involved and updated
on the project's development.
OFFICE AUTOMATION AND INFORMATION MANAGEMENT
This is the most important of the short-term obstacles to developing, implementing, and
rnaintaining a high performance, high quality EMS program. It is essential that the EMS
program be properly equipped to gather, analyze, and interpret information from all facets of
the enterprise.
The computer assisted dispatch (CAD) is the most important information management tool of
a high performance provider agency. There are three components in a comprehensive CAD
system: hardware, software, and personnel. Many CAD systems are moving to a personal
computer-based configuration rather than using a mainframe computer because personal
computers are easier and cheaper to replace or upgrade than a mainframe.
Two software packages are needed in a sophisticated CAD: resource management and
response prioritization. Resource management software tracks the status and location of
vehicles and crews to best match available resources with requests for service. Resource
management software can also include billing information, inventory control, fleet
maintenance, personnel records, and other modules or components to manage and supply
operational information.
Response prioritization software is the basis for prioritizing resources and providing pre-
arrival instructions to callers with a medical emergency. Changes in the market mandate that
resources be utilized according to medical necessity rather than an automatically committing
all available resources to each service request. Only state-of-the-art prioritization software
has the capability of adjusting to evolving community standards.
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September 1996
The third component, personnel, needs to be able to focus on those tasks associated with fire
and EMS communications. Information gathering and analysis will be an essential element
of the communications function in a sophisticated and high performance EMS system.
Information management for the entire enterprise will be predicated on information that can
only come from the dispatch center. Communications personnel should be committed to a
single procedural style. The data gathering and information management requirements of
fire/EMS are distinctly different from those of police and should not be intermingled.
Quality management and continuing education for field personnel are areas where lack of
information services could imperil the overall success of the program. The ability to monitor
performance in all aspects of the organization and provide ongoing adjustments and feedback
to operational processes will directly affect the ability of the organization to adapt
appropriately to changing market conditions. The key to this adaptability is information
gathering and analysis. It is crucial that the EMS program have the tools and skills to review
fully all internal and external strengths and weaknesses. Basic tools for information
management include personal computers in all stations and word processing, spreadsheet,
and database software. Additional software such as a local area network (LAN), statistical
analysis, presentation, and planning software are also useful tools.
IMPLEMENTATION OF SYSTEMS FOR CLINICAL AND OPERATIONAL ACCOUNTABILITY
There would not be any difficulty in implementing quality management systems. The
difficulty would be in changing the orientation from after-the-fact error correction to forward
looking system-wide process improvement. Another difficulty would be maintaining the
level of commitment necessary to realize the maximum benefits to the financial and
operational health of the EMS program.
Most quality management programs suffer from a lack of understanding about the links
between quality management, education, and performance. The goal of sophisticated quality
rnanagement programs is to identify current performance levels and establish an acceptable
range of variability, then work to narrow the range of variation and raise the level of
performance. Sophisticated quality management provides incremental improvements to the
entire organization, while after-the-fact error correction makes improvements one person at a
time.
MEDICAREIMEDICAID PROVIDER ELIGIBILITY
Becoming a MedicareIMedicaid provider is a routine transaction that should not present any
difficulties for the department. The billing agency can provide assistance in submitting the
appropriate paperwork.
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City of San Bernardino
September 1996
LONG TERM OBSTACLES TO IMPLEMENTATION
MANAGED CARE IMPACT/HEALTH CARE REFORM
Health care reform has moved beyond a policy debate and is now driven by global market
forces. In a world market economy, where U.S. workers are competing with third-world
workers, U.S. products cannot remain competitive while carrying the costs of a health care
system that costs more than two-and-half-times the next most expensive system. Driven by
tremendous cost savings, accrued as a result of changes in health care payment practices
(primarily the use of prospective payment or capitation), managed care organizations are
rapidly becoming the largest percentage of payers for health care services.
Through changes in the reimbursement of medical expenditures, managed care organizations
(MCOs) have been successful in holding down the rate of inflation for health care services
and, therefore, the cost of health coverage to employers. To fully comprehend the
implications of managed care, it is important to have a unified definition. Managed is
defined as an organized system of care seeking to influence the selection and utilization of
health services (including preventive care) of an enrolled population and ensuring care is
provided in a high-quality, cost-effective marmer. The success of these organizations at
holding down costs when others have failed can be attributed to the application of three cost-
controlling strategies:
. Pathway management (gate-keeping or access management)
. Division oflabor (increased use of non-physicians or physician extenders)
. Alignment of economic incentives (capitation)
Costs are contained by managing more effectively the utilization of health care services
through pathway management. Pathway management processes attempt to ensure the patient
is directed to the most appropriate level of treatment based on the presenting condition.
Since primary care physicians (PCPs) and other capitated health care providers are now at
risk financially for all health care related costs, it is in the best interest of the PCP to respond
with or refer to a less-expensive alternative.
In addition, health care providers are improving financial performance by capitalizing on a
division of labor that uses physician-extenders and other allied health care professionals to
perform routine medical exams and other procedures once performed by more expensive
physicians. For example, a primary care practice can process more patients during office
hours by replacing one group physician with two less expensive physician assistants and
using the remaining physicians for those procedures that actually require a physician. Other
non-physicians are performing a host of preparatory and diagnostic procedures. Essentially,
medicine is rapidly incorporating the principles of assembly line processes and statistical
process controls to mass-produce medical care.
Furthermore, MCOs are negotiating contracts with health care providers for health care
services on a prospective fee basis. Using per member, per month (PMPM) fees, this method
of payment constitutes a prospective approach to payment and is referred to as capitation. A
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City of San Bernardino
September 1996
capitated system of payment places the risk of over-utilization of services on the provider
(i.e., physician, ambulance service) and effectively reverses financial incentives from
consumption to conservation. The health care provider attempts to predict health care
consumption over a period of time for a specified population and then negotiates a
prospective payment or fee for providing services. Capitation places the health care provider
at risk, so he or she must control health care consumption, and therefore expenses, in order to
make a profit (or break even, if a nonprofit organization).
Although the cost of prehospital treatment and transportation is relatively insignificant
compared to other health care costs, the delivery of an HMO member to an "out-of-plan" or
noncontracted facility is costly. Additionally, economic efficiencies obtained by
concentrating medical technology in specialty centers has resulted in a growing volume of
interfacility and home-to-facility ambulance transports. The "specialty care" transportation
component of ambulance or medical transportation providers is the most profitable business
activity. As with other aspects of medical care, MCOs want to control cost through
prospective reimbursement or capitated contracts. To reduce administrative costs, these same
organizations want to establish agreements with large regional providers of medical
transportation and out-of-hospital services.
To be successful in this changing environment, EMS and medical transportation providers
will have to identify methods of operations that do not negatively impact large institutional
consumers of services (managed care) and their members. Successful strategies in the new
health care environment will include identification ofMCO needs and alignment of
operational practices to meet those needs while providing sound clinical care. Broadly
stated, medical transportation providers will need to rnake the following changes in
operations:
. agree to take non-urgent patients to "in-plan" facilities rather than to the closest
hospital, without regard to municipal boundaries.
. participate in regional networks with other medical transportation providers, both
emergency and non-emergency, to provide one-stop shopping for specialty care
services and a single point for the MCOs to contract for service.
MCOs are seeking alternatives to expensive, and in many cases urmeeded, patient transports
to the emergency department. In capitated reimbursement environments, the financial
incentives are turned 180 degrees. Providing services results in a cost to the provider rather
than producing revenues, as is the case in fee-for-service. These costs are without a
corresponding increase in revenues since the provider is paid prospectively (up front).
Therefore, health care providers will seek less expensive alternative services or devise ways
of reducing service consumption.
Given that Southern California has high managed care penetration within the privately
insured ranks and that state and federal government agencies are quickly moving toward
managed care for relief from risks associated with spiraling Medicaid and Medicare costs,
San Bernardino's health care delivery is being shaped by managed care. Since EMS from a
cost perspective is relatively small, it has not had the enormous financial pressure other
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City of San Bernardino
September 1996
health care providers have encountered when dealing with MCOs. But rest assured, it will.
Any proposal to provide' medical transportation must contain provisions for specialty care
services and a willingness to transport managed care members to any location within the
region.
CONTINUED ORGANIZATIONAL COMMITMENT TO EMS DELIVERY
Emergency medical services is the ultimate health care safety net. It is the only component
of health care that does not verify ability to pay before delivering service. When a call for
help is received, fire department and ambulance personnel respond to the scene without
regard to the economic or social status of the person in distress. Any person who perceives
an emergency is granted access to resources immediately.
In addition, because the City of San Bernardino has assumed the responsibility for providing
911 communications services, fire department paramedic first response, and is considering
adding ambulance transportation, the City has the moral and legal obligation to provide these
services at a level adequate to ensure competent delivery. To emphasize this point, there
have been no successful civil suits against a municipal government who has provided
adequate equipment, training, supervision, and procedures in the delivery of ernergency
services.
In the past, the department has provided paramedic care as a quasi-business, but with little
need or desire to explore opportunities or alternatives. By entering the emergency medical
transportation business, the City would be participating in a highly competitive industry in a
dynamic and evolving marketplace. The fire department is prepared to compete fairly and
compare its performance to professional standards. However, in order to be successful, there
must be an ongoing and serious commitment to provide a high quality service that is
adaptable to changing conditions.
This updated feasibility study indicates this enterprise can be self-supporting and provide
some savings to the General Fund, but those conditions will not exist for long without
support from administrative and elected officials. The proposed structure of the transport
program is an initial commitment of City resources. The program is designed to be adaptable
to changing conditions, but in order to adapt, personnel needs may change, new products
developed or old products eliminated, and new relationships formed. This is not a static
model and all components have to have the ability to function at maximum effectiveness and
efficiency over an extended period of time.
COMPLIANCE WITH PERFORMANCE REQUIREMENTS
The department has the capability to conform to any performance requirements imposed by
the City, County, or State. What it is does not have are the tools to monitor and modify its
performance to maintain acceptable levels. Information gathering and analysis from dispatch
and quality management programs are the key to compliance and need to be incorporated into
any operational system.
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City of San Bernardino
September 1996
CAREER PATH
The organization, distribution, and fire-ground activities of department resources necessitates
a structured and organized method ofresource allocation and control. The department's
command structure, which exists in nearly all fire departments, is a paramilitary model of
command which facilitates coordinated movement of large numbers of resources in
environments requiring rapid decision making.
The majority of actual day-to-day operational decision making occurs at the first line
supervisor level-the engine and truck company captain. The department's comprehensive
Standard Operational Procedures (SOP) manual ensures coordinated operation of each
emergency response unit without direct supervision from upper management. This structure
is well suited for a wide array of emergency response situations. This same structure also
provides an extensive career ladder to department personnel.
Although typically not a supervisor, the engineer rank is considered a promotion and results
in an increase in pay and responsibility and is second in command after the captain. This
position, as with the captain, is granted after an extensive and objective promotion process.
In addition to line positions, there are administrative positions within the department.
Therefore, department personnel have both supervisory and non-supervisory positions
available as part their career development. There are also administrative positions available
after appropriate training and successful completion of the selection process.
The proposed transport program identifies six new administrative and support positions.
There may be firefighters with the interest and aptitude to be successful candidates for those
positions. Also, as the program evolves and develops, new positions may be created that
would provide additional opportunities. In addition, the EMS Division will present
opportunities for the utilization of new skills. Perhaps a field training officer (FTO) to
provide guidance to paramedic students or new employees may be necessary to ensure
standardized training. One of the exciting parts of a new program is identifying a need and
providing a solution. These needs and solutions will create formal and informal career
development opportunities.
RESPONSIVENESS TO CUSTOMERS
On an individual basis, there is no question fire department personnel are responsive to their
customers. Firefighters and firefighter/paramedics treat their patients with dignity and
respect and provide appropriate care within the medical protocols of the county. In addition,
the fire department has an excellent reputation with the community and is regarded with a
high level of trust and confidence.
However, responsiveness to customers also means adaptability to changing economic and
market conditions. The proposed organizational structure is designed to scan the
environment and identify business threats and opportunities. All indications are that
emergency medical transportation alone is not going to be a sufficient product for long-term
survival.
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City of San Bernardino
September 1996
In light of the strategies that MCOs and capitated health care providers employ, prehospital
providers have considerable value because of their potential control over or impact on
pathway management, division oflabor and service consumption. Since citizen access to
EMS is through the 911 system, without significant medical triage, nearly all requests for
assistance result in the arrival of an EMS responder. EMS providers have four opportunities
to intervene or manage the pathway a patient follows before he enters a health care facility,
and thereby either increase or decrease health care costs. The following list describes four
opportunities to manage health care system access.
The First Opportunity: Public Education
The first opportunity to impact health care consumption is through public education efforts
directed at injury prevention (e.g., fall prevention and bicycle and pool safety), wellness,
medical self-reliance and appropriate use of the 911 system. Although public agencies, more
specifically the fire service, have been proactive in identifying and satisfying public
education needs, shrinking municipal budgets are forcing re-evaluation of essential vs non-
essential activities. Since the value of injury prevention, wellness and medical self-reliance
is substantial to health care providers, it is reasonable to assume MCOs would invest in those
activities if the public sector curtailed its involvement or did not pursue the business
opportunity.
These public education products would have value to managed care organizations because
these programs a) already exist and b) are proven (but not documented) to be successful. In
light of managed care's interest in keeping people out of the hospital, public education is a
less expensive alternative to treatment. Therefore, MCOs may be willing to pay for an
existing, successful program instead of paying to develop from scratch a duplicate product.
The Second Opportunity: Communications
The current practice in rnany locations of having patients self-diagnose by deciding which
telephone number to call (911 or toll free) is dangerous, disrupts the continuum of care and
adds to the difficulty of quality management activities. By ensuring the most appropriate
resources respond to a request for medical aid, EMS will have a positive impact on the
containment of health care costs. Using medically sound protocols, trained communications
specialists operating within a centralized communications center can safely provide self-help
instructions and respond the most appropriate medical resource to callers. More .accurate
allocation of resources has value as a communications product because it helps reduce costs
associated with emergency care.
The communications center has the capability to provide other non-emergency value-added
services as well. The mere existence of the communications center provides a business
opportunity. Ifa MCO has access to the communications assets of the city, there is no need
to invest millions of dollars to build its own. An outcome of this process may be something
other than an EMS system response (e.g., home health care nurse, nurse advice, scheduled
office visit).
Emergency Care Information Center
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City of San Bernardino
September 1996
The Third Opportunity: First Response
The third opportunity rests with the first responder. Multi-role/cross-trained advanced life
support (ALS) first responders provide rapid response medical assessment and treatment.
With appropriate training, first responders can assess or treat-and-refer. In this capacity, first
responder agencies like the San Bernardino Fire Department can perform pathway
management for those patients who could not be safely referred following their initial phone
interrogation by emergency medical dispatchers (EMDs). MCO representatives have
responded positively to EMS agencies who desire to provide or aid in pathway management
Conducting activities such as risk assessments while first responder units wait for their next
call creates an revenue generating opportunity for the fire department. Either through direct
fee- for-service billing or as part of a prospective "per member per month" fee arrangement,
engine companies currently conducting fire inspections could conduct risk assessments.
For example, an MCO such as Secure Horizons could contract with the fire department to
inspect high-risk members' homes for unsafe conditions (e.g., throw rugs, extension cords,
slippery bath tubs, etc.) that might increase the probability of a fall. A relatively small
reduction in the incidence of falls in these high-risk members' homes would produce
substantial savings for Secure Horizons.
At anytime during the inspection the engine company could respond to an emergency, just as
they do from fire inspections today. The ability to perform multiple tasks while waiting for a
response is available capacity. The fire service is, without exception, best suited for this
activity given their extensive experience in fire prevention and the high level of public trust
bestowed upon them.
The Fourth Opportunity: Mobile Medical Services and Transportation
The fourth opportunity rests with the transport agency and its ability to provide patient
transportation services and carry specialized equipment. In light of present scope-of-practice
issues, the most significant impact of the transportation component rests in its ability to
further manage patient pathways by transporting the patient to his or her "in plan" or
contracted facility when medically appropriate. Other potential value-added opportunities
exist in the mobility of the service provider and the ability of the agencies to bring
sophisticated care to the patient, thus potentially reducing costs associated with the
maintenance of two systems---one of brick and mortar (hospitals and clinics), the other
mobile and significantly more flexible.
Since the first responder unit is already an existing cost to the City, using it to respond to
minor incidents or responses with a low likelihood of requiring transportation is more
economical than responding an ambulance. Ambulances and their staff are a single-function
resource; therefore, their cost must be recovered exclusively through fee-for-service or
capitated revenue sources. The current number of ambulances, and therefore EMS system
cost, is based on historical ambulance need. Reducing the number of responses and
ambulance transports through pathway management activities, including emergency medical
dispatching, use of tertiary triage (Ask-a-Nurse) and first responder assessment, can result in
significant savings to capitated EMS providers.
Emergency Care Information Center
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City of San Bernardino
September 1996
COST RECOVERY/ FINANCIAL EFFICIENCY
The proposed transport program is designed to operate at cost-recovery under all operational
scenarios. The financial structure of the program will match revenues to expenses
automatically and reflect the budgetary policy of the City Council.
The question of financial efficiency is directly related to the program's information gathering
and analysis capability and the continued support of administrative and elected officials. If
the conditions described in other parts of the report are met, the San Bernardino Fire
Department will have the tools and capability to operate a technically sophisticated and
financially efficient emergency ambulance transport program.
Since the transport program is designed to be self-supporting during operations, it also makes
sense the start up be financially efficient. To be financially efficient, the fire department
could borrow the funds necessary to begin the enterprise from the City using well-established
internal procedures. The transport program would repay the loan with interest using proceeds
from user fees within an interval acceptable to those with financial oversight responsibilities.
This repayment period would most likely be between two and five years.
The time necessary to transition to full operational status depends on several factors. First is
the design of the organizational structure. This includes job descriptions, lines of
communication, and performance criteria. The first position filled should be that ofthe
program director. This person must be an experienced EMS executive with strong leadership
skills and a comprehensive understanding of the changing and dynamic environment. The
second position filled should be that of the quality manager. This person will establish the
internal controls and external scanning techniques of the organization. At the same time the
quality manager is selected, a medical director needs to be incorporated into the management
team.
The program director needs to be in place at least six months before the transport program
begins operation. The process for recruiting and selecting the program director could take six
months to a year, depending on the requirements of the city when creating a new executive
position. After the program director is in place, several events can proceed more or less
simultaneously: ambulance specifications and purchase, field protocol development,
equipment and supply purchasing, evaluation and selection of a billing agency, and the
administrative activities necessary for the fire department to become a properly accredited
emergency transport agency. The entire start up process will most likely take at least one
year, perhaps longer.
However, once the department begins transporting patients, it will take an additional three to
six months to establish a steady and reliable cash flow. This assumes complete billing
information is collected for all patients by field personnel and an experienced medical billing
service is used to process claims.
Emergency Care Information Center
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City of San Bernardino
September 1996
IMPACT ON THE GENERAL FUND
REVENUE PROJECTIONS
The revenue model presents the minimum reliable cash available to support emergency
medical transportation in San Bernardino. If the City chooses to use the current retail fee
schedule and the forecast call volumes are met or exceeded, the armual revenues identified in
the model would accrue to the City. However with this scenario, the City is likely to
accumulate funds that exceed the legal requirement for local governments operating a
business to charge fees sufficient only to recover costs and not generate "profits." Business
decisions that could affect revenues include whether to create a "contingency fund" to
provide short-term operating funds, how start up costs will be repaid, whether to continue the
first responder fee and under what circumstances, billing and collection policies, and which
opportunities are pursued or threats avoided.
ECIC did not calculate a new fee schedule designed to cover exactly costs contained in the
expense model. Instead, the cost-recovery average bill is the result of the year's total
expenses divided by the total number of transports to create an armual cost per transport. The
cost per transport is divided by the collection ratio to determine the bill necessary to generate
the exact amount of cash to match expenses. The average bill from the revenue model is
$733, while the average bill necessary to provide exact cost recovery is $648 during the first
operational year. This means, depending on the business decisions made by the City, the
average ambulance bill for the citizens and visitors to San Bernardino could be lowered by
more than $75. However, this lower average bill does not include any amount for repaying
start up costs.
Revenue projections are organized into three sections: EMS Responses, ALS Billing and
Revenue, and BLS Billing and Revenue. The EMS responses section presents the projected
number of 911 requests-for-service (total EMS responses), the number of expected transports,
and the breakdown of those transports into the various billing categories used to determine
how patients are billed. ALS Billing and Revenue is the fraction of the total EMS revenue
attributable to ALS transports. BLS Billing and Revenue is the fraction of the total EMS
revenue attributable to BLS transports. Revenue projections are intended to show what an
ambulance provider in the City of San Bernardino could expect to obtain rather than the
revenues that may be available in a county-wide program.
ALS Billing and Revenue is divided into three billing categories: ALS Transport, Mileage,
and Oxygen. BLS Billing and Revenue is also divided into three billing categories: BLS
Transport, Mileage, and Oxygen. ALS and BLS are separated to accommodate the different
prices for ALS- and BLS-level goods and services. However, the "retail" ALS Transport rate
and the BLS Transport rate are identical as authorized by the county.
For the purpose of conservatively and accurately estimating the amount of revenue the City
could reasonably expect to earn, each billing category is separated into four parts: the
"Retail" price, the "Medicare" price, the "Medicaid" (Medi-Cal) price, the "Billed" amount,
and the probable "Collected" revenues. The "Retail" price is the maximum user fee allowed
Emergency Care Information Center
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City of San Bernardino
September 1996
by ICEMA and the "Medicare" price is the allowable charge specified in the Medicare Part B
Prevailing Charge Report Inflation-Indexed Charge (IIC) Schedule for ambulances.
Reimbursements are based on either the "Retail" price or the "Medicare" price.
There are four primary sources of payment: Medicare, Medi-Cal, insurance, and private
payment. Medicare is the federally funded medical insurance program for the elderly. Medi-
Cal is the federally funded, state-administered medical insurance program for the poor and
the disabled. Insurance is private insurance, including all fee-for-service and health
rnaintenance organization (HMO) coverage plans. Private payment is that portion of the
patient population which pays for medical care with personal funds.
In San Bernardino, the payer mix is estimated to be:
Medicare: 30 percent
Medi-Cal: 17 percent
Insurance: 45 percent
Private pay: 8 percent
The gross revenue projection amount is the product ofthe number of transports multiplied by
the paramedic "Retail" rate. This maximum amount is identified on the spreadsheet in the
"Billed" column. However, ambulance companies rarely collect the entire amount billed.
Therefore, this preliminary figure is modified by different factors resulting in the subtotals
and totals shown in the "Collected" column. To completely calculate the revenue amount for
each category, both the "Total Transports" and the "Retail" rate have to be modified to
reflect billing and reimbursement requirements.
The first modification of "Total Transports" is to multiply the number of transports by the
values for specific billing categories (i.e. ALS or BLS, mileage, or oxygen). The second
rnodification is to multiply the number of transports by the payer mix percentage. This
properly allocates that portion of the funds attributable to a particular payment source.
(Medicare patients are 30 percent of the local patient population, therefore, 30 percent of the
transports will be billed to Medicare.) Thus, the number of transports is modified both by the
patient population's payer mix and by the specific billing category.
Medicare will pay a percentage (80%) of the allowable charge for each billing category to
ambulance transport providers. Reimbursement is not available for rendering service without
transport. Medi-Cal is the California designation for Medicaid. This social medical
insurance for the poor pays a fixed amount, but much lower than the retail or even Medicare
prices, for ambulance service. Again, patient transportation is the key component for
reimbursement.
Traditional medical insurance generally pays most (an average of 90%), but sometimes not
all of the billed amount for ambulance transportation. Insurance payers, in effect, receive a
discount off the retail ambulance transport bill. Insurance (fee-for-service and Health
Maintenance Organizations) covers the largest percentage of the patient population in San
Bernardino. However, some patients pay an ambulance bill completely from personal funds.
Page 23
Emergency Care Information Center
City of San Bernardino September 1996
This portion of the patient population is most sensitive to price changes. As the amount of
the bill increases, the ability and willingness to pay decreases.
Wittman Enterprises estimate that 40 percent of the "private" category will pay the amount
billed for any given category. Forty percent is chosen to recognize and accommodate
customer reluctance to pay a bill from a government already collecting taxes, varying degrees
of "sticker shock" from the perception of high prices, and the delays in collecting "payment-
in-full." For the purposes of this study, the revenue estimates for private payment in each
billing category are further reduced by 50 percent to provide the most conservative estimate
of probable receipts in anticipation of bad debt and delayed payment.
The rate in the "Retail" column is modified by Medicare Schedule IIC ("Medicare" column)
and by the discounted percentage allowed by the payer. The "Retail" rate is replaced by the
"Medicare" rate for Medicare patients and also is discounted to reflect Medicare's allowed
payment percentage. The other payers reimburse a percentage of the billed amount, so the
"Retail" rate is multiplied by the appropriate percentage. (Insurance pays 90 percent of the
billed amount; therefore, the amount of the revenue received is ten percent less than the
amount billed.) The paramedic ambulance "Retail" rate is modified by Schedule IIC and the
discounted reimbursement percentages. The dollar amount shown on each payer line in the
"Collected" column of the spreadsheet is the product of "Total Transports", billing category,
payer mix percentage, "Retail" or "Medicare" rate, and discounted percentage.
The collection ratio is the "Collected" amount divided by the "Billed" amount. In revenue
projections for San Bernardino, the collection ratio is calculated to be approximately 58.5
percent. The Heinick-Apple "Private Ambulance Financial Survey- 1992-1993"4 reports the
collection ratio in the region that includes California to be 74 percent and nationally to be 73
percent. The 1990-1991 survey reported 73 percent in the region that includes California and
78 percent nationally. Additionally, the AAA contracting guide reports collection rates for
911 services range from 58 to 68 percent.
Revenue estimates do not include copayments, deductibles, additional goods or services (e.g.
disposable supplies), or special assessments (e.g. dry run or false alarm, drunk driver
incidents). These amounts are generally the responsibility of the patient, and therefore,
subject to the same perceptions that affect private-pay bills. In order to present the most
conservative revenue projection, these billed amounts are not included in the projections
because they may not be reimbursed by third-party payers and are subject to bad debt and
delayed payment.
4
Heinick, Apple & Company, certified public accountants, is a private accounting
firm that each year conducts a financial survey on behalf of the American
Ambulance Association. This survey can be considered a benchmark of private
ambulance provider financial performance.
Emergency Care Information Center
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City of San Bernardino
September 1996
An ambulance service provider has the option of accepting "assignment" for Medicare (or
any other third-party payer) reimbursement. If a provider accepts assignment, the Medicare
allowable charge is accepted as the full amount collectible for the ambulance transport bill.
In other words, Medicare pays 80 percent of the allowable charge and the patient (or the
secondary insurance) pays the remaining 20 percent copayment.
The difference between the amount of the ambulance transportation bill and the amount
reimbursed by the various payers is the responsibility of the patient. This difference may be
referred to as a deductible and/or copayment. A deductible is a first-dollar payment (usually
a fixed amount) made by the patient before insurance coverage is applied to the amount
owed. A copayment is a proportional amount of the total due that is the responsibility of the
patient. It is possible for a patient to be responsible for both a deductible and a copayment.
For example, if the total ambulance bill is $100, and an insurance payer requires a $10
deductible and a 20% copayment, the patient pays $10 as the deductible and 20% ofthe
remaining $90. Twenty percent of $90 is $18, so the patient is responsible for the $10
deductible and the $18 copayment for a total out-of-pocket payment of $28. The insurance
payer submits the remaining $72.
EXPENSE PROJECTIONS
PERSONNEL, EQUIPMENT, AND ADMINISTRATIVE
Personnel expenses for existing and new personnel were calculated using payroll and benefit
values provided by City Human Resources and City Finance Offices. Existing personnel
costs were based on labor agreements in place during this project. New positions used salary
schedules for equivalent positions within the City's listing of job titles. Benefits were
calculated as a percentage of armual salaries for each appropriate payroll category. Annual
incremental increases were based on historical changes for each payroll category. No
allowances were made for positions that may be necessary in the future as result of changing
organizational needs or evolving environmental factors.
Medical supplies and equipment expenses were based on current prices identified in
appropriate catalogs or vendor price lists. In the case of catalog items, more than one catalog
was consulted and an average price calculated for all items when possible. Equipment costs
include electronics and vehicle modifications necessary to conform with fire department
standards. Costs are based on all vehicles and personnel being completely supplied with all
new inventory with no consideration for existing or duplicated material. To the extent
existing supplies and equipment can be utilized, initial purchase expenses will be less than
calculated.
Administrative expenses are presented as a single line item labeled "Overhead." This amount
is calculated as 14 percent of the sum of all other expenses for the year. Overhead charges
are a direct payment to the City by the EMS enterprise fund. However, the amount presented
in the expense model will change based on actual expenses incurred by the EMS Division.
All capital items identified in the expense model also have a corresponding depreciation
Emergency Care Information Center
Page 25
City of San Bernardino
September 1996
expense calculated using straight-line depreciation over the expected life of the asset.
Ambulances are leased, and represent an ongoing operational expense rather than a
capitali:z;ed purchase. Therefore, there is no depreciation expense associated with
ambulances. Administrative vehicles, however, are purchased and depreciated over their
expected life.
LIABILITY
The most significant risk exposure to the San Bernardino Fire Department is vehicle
collisions resulting from operator error, failure to yield by another vehicle, or vehicle systems
error. California statutes define the requirements that must be met for emergency vehicles to
operate outside the ordinary laws of the road when responding to emergencies. SBFD
apparatus respond in the emergency mode using red-lights-and-siren (RLS). Fire department
vehicles using RLS are granted certain exceptions to a limited set of traffic laws, however,
the statutes clearly state that at no time are drivers permitted to operate the vehicle in an
unsafe marmer.
We do not anticipate a significant increase in liability associated with vehicle operation since
the we are proposing that the department implement a program to prioritize the dispatch of
BLS/ ALS resources. The prioritization of requests for EMS should significantly reduce the
number of multiple company responses and use of red-lights- and-sirens. Therefore, any
potential increase in risk exposure that may result with an increase in EMS responses for
SBFD would be offset by the use of priority dispatch protocols.
The doctrine of governmental immunity has eroded somewhat over time. Charges of
negligence can be made against individual fire fighters, the department, as well as the City
itself. Fire fighters are at risk in the performance of their duties, and the Department and City
are at risk for negligent supervision and training.
In any activity involving the potential for accidental death or injury, there is the potential for
all parties who may have been in any way responsible for preventing or causing the death or
injury to be charged with negligence in a civil action initiated by the injured party or parties
or their survivor(s). Charges of negligence may arise from: failure to render an obligated
service, failure to recognize a life involvement (either in general or to a specific person)
during an emergency, administering improper medical treatment, vehicle accidents caused by
improper maintenance of department vehicles or inadequate driver training, and failure to
keep adequate records.
There are no documented reports of any related negligence claims or suits being filed against
the department since it began offering out-of-hospital emergency medical care. It is our
impression that San Bernardino firefighters are highly trained and dedicated professionals
who are aware ofthe legal potential of delivering emergency medical care. In addition,
California statutes provide protection to emergency workers who act within the scope of their
training and in good faith.
Emergency Care Information Center
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City of San Bernardino
September 1996
Although paramedic personnel perform more medical skills and treatments than their EMT-D
first-responder team members, they are also more closely monitored and have on-line access
to physicians for direction and consultation. The proposed quality improvement and
assurance activities would provide an additional measure of medical liability prevention for
SBFD. Recent research into the claims experience of two large EMS system found that
claims occurred approximately once every 25,000 patient contacts and that the average claim
was approximately $15,000 dollars.5.6
Personnel are exposed to disability-producing hazards when responding to medical
emergencies, while driving to and from incidents, during training, and during physical fitness
training. Common exposures include eye injuries from the breaking of glass; cuts and
lacerations from broken windows and other sharp objects; slips and falls; and debris from the
use of power extrication tools. Strains, sprains, and back injuries may result from carrying
victims or equipment.
Presently, SBFD first responders and paramedics are assisting ambulance paramedics with a
variety of patient care and extrication activities. Although implementation of an ALS
transport component would to some extent increase patient handling activities by SBFD
personnel, increased coordination and familiarity between first responders and the ALS
ambulance-based firefighter/paramedics is anticipated to reduce on-the-job injuries.
Therefore, we do not anticipate workers compensation claims to increase significantly as a
result of the implementation of emergency ambulance transport.
5
Soler JM, Montes MF, Egol AB, et al: "The I 0- Year Malpractice experience of a
Large Urban EMS System." Annals of Emergency Medicine, 14:982-985, 1985.
Goldberg RJ, Zautcke JL, Koenigsberg MD, et al: "A Review of Pre hospital Care
Litigation in a Large Metropolitan EMS System." Annals of Emergency Medicine.
19:557-561,1990.
6
Page 27
Emergency Care Information Center
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September 1996
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September 1996
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September 1996
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City of San Bernardino September 1996
Expense Model
Start Up Year 1 Year 2 Year 3 Year4 Year 5
Personnel Costs 1997
FFIPM existin9
FFIPM new 1.389,089 1,478.322 1,567,579 1.659,587 1,753,519
Contingency OT 198,441 211,189 223,940 237.084 250,503
Program Director 106.640 111.173 113,397 115,665 117,978 120,338
Medical Director (.2 FTE) 60.000 62,400 64,896 67,492 70,192 72.999
Quality Manager 85.265 88.926 90,704 92,518 94.368 96.256
Administrative Analyst 49,017 51.470 54,043 56,745 59.583 62,562
CE Director 85,265 88,926 90,704 92.518 94,368 96,256
Education Coordinator/liaison 85.265 88.926 90,704 92,518 94,368 96,256
Admin Operations Supervisor 46,630 48,961 51,409 53,979 56,678 59,512
Materials and Services
Computer Equipment Depreciation 13.750 13.750 13.750 13.750
Equipment Maintenance 10,472 10.891 11,327 11,780 12,251
Fuel and lubricants 64,615 65.486 66,358 67,229 68,101
Infection Control 37.837 27,634 28,739 29,889 31,084 32.328
FF Equipment 83,038
Medical Equipment - Depreciation 89.122 89,122 89,122 89,122
Medical Supplies - Start Up 45,288
Medical Supplies - Replacement 150,388 152,432 154,477 156,521 158,565
Memberships, Books. Subscriptions 2,100 2,184 2,271 2,362 2,457
Office Supplies 3.523 3.570 3.618 3.666 3.714
Overhead 173.084 437.422 455.686 474,044 492,939 497.835
Postage and Shipping 2,769 2.806 2,844 2.882 2,919
Travel and Meetings 5,000 5,200 5,408 5,624 5,849
Vehicle lease 160,000 160,000 160,000 160,000 160.000
Vehicle Maintenance 103,532 104,939 106,347 107.754 109,161
Vehicle Depreciation 10.000 10,000 10.000 10,000 10.000
Capital Goods
Administrative Vehicles 50,000
Computer Equipment 55.000
Computer Software 20,000
Medical Equipment - Start Up 356,488
Office Furniture 5.000
ACCOUNT AND BilliNG SERVICES
Billing Agency Fee 302,277 306,386 310,495 314.604 318,713
EDUCATION AND TRAINING
Personnel
Ambulance Driver Training
Instructor Training 12.054
Driver Training 38,062
Emergency Medical Dispatch 7.614
Paramedic Training
Paramedic C.E. 45,025 47.863 50,754 53.737 56,773
EMT-D 5,856
EMT -0 Recertification 2.928 3,045 3,167 3.294 3,425
Materials and Services
Travel and Meetings 3,000 3,120 3,245 3,375 3,510
Projected EMS Gross Expenses 1,407,403 3,561,867 3,710,590 3,860,070 4,013,930 4,053,803
Revenue Model 4.354,136 4.413,328 4.472,519 4.531.706 4,590,894
Surplus/(Shortfall) 792.269 702.738 612,449 517,777 537.091
Avg. bill revenue model $733 $733 $733 $733 $733
Avg. bill gross expense $37 $648 $666 $684 $702 $700
Emergency Care Information Center Page 40