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HomeMy WebLinkAbout42- City Adminstrator CITY OF SAN BER►.ARDINO - REQUEST . OR COUNCIL ACTION From: Peggy Ducey, Assistant to the Subject: Proposed City Fire Department City Adminstrator Emergency Transport Services Dept: Adminstration Date: July 23 , 1993 Synopsis of Previous Council action: July 19 , 1993 - Mayor and Common Council continued the item until August 2 , 1993 to allow the City Adminstrator to prepare a written rebuttal; and direct staff to meet with Courtesy Ambulance to develop a solution. Recommended motion: 1 . Receive and file report from City Administrator; - and - 2 . Approve the operations plan as presented July 19 , 1993 ; - or - 3 . Continue item to first Council meeting in October to allow staff to pursue discussions with Courtesy Ambulance. nature Contact person: Peggy Ducey Phone: 5122 Supporting data attached: yes Ward: FUNDING REQUIREMENTS: Amount: Source: (Acct. No.) (Acct. Description) Finance: Council Notes: f6� CITY OF SAN BERL_,4RDINO - REQUEST . JR COUNCIL ACTION STAFF REPORT On July 19, 1993 , the Common Council held a hearing on the proposed City Fire Department emergency transport services. After hearing testimony from Mr. Steve Rice, Courtesy Ambulance, Council directed City staff to respond to the statements made by Mr. Rice. CITY OVERPROJECTED REVENUES FOR THE PARAMEDIC MEMBERSHIP PROGRAM. Mr. Rice stated that the projected revenue for the paramedic membership program was $610,000 annually. Actual revenue for FY 91/92 was only $178,000, and actuals for FY 92/93 were only $310,500. Initial revenue projections were based on current and projected medical aid call loads, collection rates as provided by Courtesy Ambulance, and performance figures from other cities with paramedic membership programs. These initial projections were realistic, however, a number of unanticipated events have affected actual collections, including the County EMS lawsuit, paramedic double- billing, and a change in billing companies from Courtesy Ambulance to Advanced Billing Concepts (ABC) . When the Paramedic Membership Program began in July, 1991, the City contracted with Courtesy for billing services because of their fee collection experience as well as the established working relationship between the Fire Department and Courtesy. In August, 1991 after investigating complaints regarding field medical aid charges, City staff discovered that Courtesy was charging for paramedic services even in cases where only City paramedics provided medical care. Over the next few months, staff attempted to negotiate a resolution to the billing issue. During the negotiations, Courtesy expressed strong concerns about the legality of the membership program and ability of the City to charge for Fire Department services. Because of this, City staff felt that Courtesy had a conflict of interest regarding City paramedic billing and was granted approval by the Common Council to contract with an independent billing firm. This change was a sound administrative decision but hurt program revenues in the short term. Any fee-for-service program takes 4-6 months for revenues to reach projected levels. Courtesy handled billings for the first six months of the program but just as fee collection was increasing, it became necessary to change billing companies. Records turned over by Courtesy to ABC, the new billing company, were incomplete and collection rates dropped for six months. However, collections have increased in the last fiscal year. While its true revenues for FY 91/92 were only $178, 000, revenues almost doubled for FY 92/93, to $340, 000. Another reason projected revenues have not been realized is that the City cannot collect fees from Medi-Care and Medi-Cal. Initial information given to City staff indicated that the City could collect from these providers and these revenues were incorporated 75-0264 into the projections. However, once the program was implemented it was confirmed that program regulations require an ambulance transport identification number for reimbursement. This decreased the original projections by 33-40%. If the City could have I collected these, revenues would have increased last year to almost half a million dollars. If the City does begin to provide transport services, these revenues would become collectable. REVENUE PROJECTIONS FOR CITY AMBULANCE SERVICE ARE OVER-ESTIMATED. Mr. Rice states that the revenue estimates for City ambulance transport services are too high. When developing an implementation plan, staff acknowledged that ambulance collections were a specialized field and revenue estimates needed to be done by someone knowledgeable in the field. Wittman Enterprises, an ambulance billing and consulting service, was hired to perform the initial projections. Wittman currently bills for the following clients: Ace Medical Transport Waterford Ambulance Elk Ambulance Paradise Ambulance Monterey Park Fire Dept. Ramona Muni Water Dist Indio Ambulance Sanger Fire Dept Mono County Emergency Med Svs. Special Services Amb. West Side Ambulance Marin County Patterson Ambulance Basis Life Support Selma Fire Dept. Bridgeport Fire Dept. Tri-County Ambulance Huntington Beach Fire Wittman estimated user fee gross revenues would be $4 , 180, 564, with net revenues reflecting a 62% collection rate. Staff was concerned that these projections did not reflect the socio-economic conditions of San Bernardino, and requested that Advanced Billing Concepts (ABC) , the City's current billing company, review the projections. ABC confirmed that the gross projections were accurate, but that the collection rate should be dropped to 55%. At one time, Courtesy Ambulance cited a 55% collection rate to administration staff, so ABC's review was reasonable. However, to be conservative, administration staff dropped the rate to 52% of gross billings when completing its cost/benefit analysis. CITY'S TRANSPORT CHARGES ARE VIRTUALLY THE SAME AS COURTESY. Courtesy argues that City transport rates are the same as Courtesy ambulance. City transport rates will be lower than Courtesy because itemized fees such as unscheduled emergencies, night and weekend charges, etc. , will not be charged. Courtesy also has had a rate increase pending since September, 1991 that was deferred until the City resolved the paramedic double billing issue. For comparison purposes, Courtesy rates and City proposed rates are as follows: 1991 COURTESY COURTESY CITY CURRENT PROPOSED PROPOSED Basic Life Support (BLS) * $ 178 . 84 $ 214 . 60 $ 238.00 Advanced Life Support (ALS) 272 . 00 315.93 351.00 All-Inclusive ALS 403 . 75 468.84 0 Unscheduled Emergency 81. 24 85.50 0 Night Charge (7 am -7 pm) 52 . 18 60. 60 0 Weekend Charge 52 . 18 60.60 0 Mileage 8 . 94 8 .98 8.98 Oxygen 22 .37 50.98 23.00 EKG Monitoring 37 . 25 43 .25 0 * NOTE: Courtesy does not charge Basic Life Support fees on 9-1-1 calls. All 9-1-1 calls are charged the paramedic ALS rate. Based on these rates, an average ambulance bill would be as follows: Courtesy Ambulance: All 9-1-1 calls (Note: Courtesy charges ALS rates for a119- 1-1 calls). Current Proposed All-Inclusive ALS $403 .75 $ 468.84 Night Charge 52 . 18 60.60 Mileage 27 . 00 27.00 Oxygen 22. 37 50.98 TOTAL $505.30 $ 607.42 Proposed City Rate: Heart Attack Victim - ALS Proposed Advanced Life Support $ 351. 00 Mileage 27.00 Oxygen 23.00 TOTAL $ 401.00 Proposed City Rate: Broken Arm - BLS Basic Life Support $ 238.00 Mileage 27. 00 TOTAL $ 265.00 Based on the current and proposed rate schedules, City transport services would be $100 - 250 less than Courtesy. Furthermore, residents would not be responsible for paramedic charges for both Courtesy Ambulance and the Fire Department. This would decrease bills by another $100 - 200, making a total reduction in fees of $200 - 450 per medical incident. THE CITY WOULD PUT COURTESY AMBULANCE OUT OF BUSINESS. Courtesy argues that eliminating emergency paramedic ambulance transport would close their business. By eliminating Courtesy's emergency transport, there is no doubt Courtesy would change the way it operates its business. However, Courtesy would still keep all routine transport, which is the more lucrative service, as well as emergency transport for unincorporated county areas and surrounding cities. Another issue that must be addressed is that the San Bernardino City Council never formally authorized Courtesy to begin providing paramedic services but Courtesy, on its own initiative, chose to expand its services when the City did not need them. In 1975, the San Bernardino Common Council considered the provision of paramedic services in the City. A motion to designate Courtesy as the primary provider failed by a vote of five to two. A motion to designate the Fire Department as the primary provider then passed by a vote of six to one. Since the City does not have a written operating agreement with Courtesy, it is unclear when paramedics were actually put on Courtesy ambulances. When questioned by Jim Page, the City's EMS consultant, Mr. Rice stated that he first employed paramedics in the mid-1970's but did not become an all-ALS paramedic provider until October, 1990. We can infer that Courtesy did not staff and bill for paramedic services until late 1990. This was the same time that the County adopted an EMS plan that identifies private paramedics as a major component of this County wide plan. When interviewed by Jim Page, the former County Health Officer stated that the County considers it important for private paramedics to exist in the City to serve residents of the unincorporated areas. In essence, city residents pay for the duplication of paramedic services to subsidize service in the unincorporated areas. Courtesy has provided ambulance transport services for the Fire Department for over forty years. However, they did not begin charging paramedic fees on 9-1-1 calls until October, 1987 . Prior to that time, Courtesy charged a differential between non-emergency calls vs. emergency calls, but this equates to the "unscheduled emergency" charge they have now. Courtesy has argued that the City approved its ambulance rate schedule, including the ALS paramedic charge and by doing that approved the staffing of private paramedics. However, there is some confusion regarding the fees approved by Council and the application of those fees by Courtesy. It is unlikely that the Council knowingly approved the imposition of a fee for paramedic services when that service was not actually provided by Courtesy. It is also unlikely that Council would have approved the operation of private paramedics when the Fire Department had already been designated as the paramedic provider for the City. Because the City does not and has not have the authority to audit Courtesy's billings or accounting books, Courtesy's billing ' or staffing practices did not come to light until 1991. THE CITY'S NUMBER OF PROPOSED AMBULANCES IS TOO LOW. Mr. Rice argues that six ambulances and two reserves is not enough to cover the number of calls the City has. Courtesy states they responded to 19, 000 medical calls last year. According to Fire Department dispatch records, City Fire only responded to 14 , 500 medical aid calls last year. The remaining 4 ,500 calls Courtesy responded to must be for service calls other than 9-1-1 emergency calls, such as routine inter-facility transport, non-emergency transport, and emergency transport in unincorporated areas. Some may also be emergency calls where the patient has called Courtesy directly rather than 9-1-1. In these cases, Courtesy is supposed to call the Fire Department to respond, but has not done so in all emergency cases. Staff based its recommendation of number and location of City ambulances on an analysis of the total number of 9-1-1 calls and their distribution throughout the City. The City's EMS consultant reviewed the number of calls, peak times„ and average time needed for an entire medical aid call, and documented that six ambulances would be more than sufficient to staff the City. This number is reasonable since the City currently has five paramedic teams that provide services on all medical aid calls. Adding one more paramedic team would add a more comfortable service level for peak times. Two reserve ambulances would allow for coverage when vehicles are being serviced as well as major medical emergencies. For comparison purposes, Courtesy reports that they operate 12 ambulances at peak periods, with ten designated for San Bernardino. Staff reviewed Fire dispatch log books which reflect daily reports given by Courtesy regarding the number of ambulances available. For the month of June, 1993, statistics were as follows: Range - # Average # Ambulances Available Available 11:00 p.m. - 7: 00 a.m. 2 - 5 3 .46 7 : 00 a.m. - 12 : 00 p.m. . 7 - 10 7.91 12 : 00 p.m. - 5: 00 p.m. 5 - 7 6. 00 5:00 p.m. - 11: 00 p.m. 5 - 6 5. 66 During peak morning hours, it seems that more than six ambulances may be needed, however, further analysis of these statistics revealed that Courtesy covers the Cities of Highland and Colton with only one ambulance during these same peak periods. It is likely that some ambulances "officially" designated for San Bernardino are actually providing service to Colton and Highland. Also, morning hours are peak times for routine transport and San Bernardino are ambulances providing routine and inter-facility transport as well as emergency response,. The San Bernardino ambulances are also serving the unincorporated areas of the City as well. So the 7-10 ambulances operating during peak hours are actually fulfilling a number of different duties besides 9-1-1 service to San Bernardino. Mr. Rice questions whether minimum ambulance coverage will lead to call screening, and the poor will be selectively served. As shown above, six ambulances are more than adequate to cover medical aid calls. However, dispatch policies of the San Bernardino Fire Department requires that staff respond to all 9-1-1 calls no matter what the situation. Fire stations are strategically located throughout the City to equally serve the entire community and in fact, if approved, 4 out of the 6 ambulances would be stationed in areas considered low income. CITY FIRE DEPARTMENT PARAMEDICS ARE MUCH MORE EXPENSIVE THAN COURTESY PRIVATE PARAMEDICS. Mr. Rice cited that City paramedics are paid $69, 000. Actually, City medic pay and benefits ranges from $56, 000 - $64, 000, $5, 000 - 13, 000 less than cited by Courtesy. Also, city paramedics are multi-function staff, trained not only for medical aid, but fire suppression, hazardous materials response, search and rescue, and heavy rescue. By comparison, Courtesy paramedics salary and benefits are $39, 000 - 45, 000, but Courtesy staff provides only medical aid response. NECESSITY OF TWO PARAMEDICS VS. ONE PARAMEDIC AND AN EMT. Mr. Rice argues that it is not necessary to have two paramedics to provide good medical care. Courtesy Services staffs its ALS units with one paramedic and one EMT, while the Fire Department staffs with two paramedics. Eighty percent of all Fire Departments and sixty-seven percent of primary paramedic providers for the nation's most populous 200 cities staff ALS units with two paramedics, and there is sound medical reasons for doing so. Two-person medic teams specifically divide responsibilities to allow for optimum patient care. On medic, called the "patientman" takes and monitors vital signs and administers treatment to the patient, while the other "radioman" interfaces by radio with the hospital. doctor to exchange information regarding the patient's condition and medical treatment per the doctor's orders. The "radioman" also prepares any drugs necessary to stabilize the patient's condition and directs the "patientman" to administer the drugs and other treatments. More importantly, two paramedics act as a check and balance system for each other to ensure that no fatal mistakes are made in the field. A 1980 study performed by the Philadelphia Department of Public Health reviewed 200 consecutive prehospital heart attack incidents where half were handled by two paramedics and half were handled by an EMT and one paramedic. Researchers found that there were no survivors among patients treated by only one paramedics, while 16% of patients treated by two paramedics survived. Furthermore, the American Heart Association took a formal position in October, 1992 advocating for the staffing of two-paramedic teams. PATIENT DIED OF HEART FAILURE AND COURTESY TOOK 18 MINUTES TO ARRIVE ON-SCENE BECAUSE THEY WERE DISPATCHED 11CODE 211. Mr. Rice stated that a good friend recently had a heart attack. The Fire Department dispatched Courtesy "Code 211, without red lights and sirens, and it took them 18 minutes to arrive on-scene. Administration staff has reviewed both the Medical Aid report as well as the dispatch tapes to determine specifics of the incident. Events happened as follows: 6:47 9-1-1 call from patient's wife reporting that her husband is having convulsions. First-responder engine company and paramedic engine are immediately dispatched. 6:48 Courtesy ambulance is dispatched by phone, "Code 2" (no lights and siren) . Courtesy reports their location at the Crosstown (30) Freeway and Del Rosa. 6:51 First-responder engine arrives on-scene. Takes vital signs, which are strong. Patient is able to converse with Firefighters. 6: 54 Paramedic engine arrives on scene. 6: 55 Vital signs taken again. Patient's condition is deteriorating. 6: 56 Paramedics hook patient up to heart monitor. Indicates third-degree heart blockage. Paramedics ask dispatch to upgrade Courtesy to "Code 311. 6:59 Courtesy is upgraded by dispatch to "Code 311 , red lights and siren. 7: 01 Dispatch calls Courtesy with directions to incident. 7: 03 Dispatch calls Courtesy requesting an estimated time of arrival and again gives directions to the scene. Courtesy reports location and dispatch realizes Courtesy has headed in the wrong direction to get to this address. Dispatch again gives directions to Courtesy. 7:06 Courtesy arrives on scene. Initially Courtesy was dispatched Code 2, but was upgraded to Code 3 within minutes after paramedics arrived on-scene. Courtesy reported that they were at the 30 Freeway and Del Rosa. The incident was located less than four miles away. Traveling within the posted speed limit, it should have taken Courtesy less than six minutes. When Courtesy did not arrive within ten minutes, Fire dispatch called to determine the problem. When Courtesy reported its location, dispatch realized that they were traveling on a street that dead-ended and they would not be able to reach the incident location. Dispatch radio'd directions three times to Courtesy. Courtesy arrived on-scene 18 minutes after being dispatched because they were lost, not because they were dispatched Code 2. The controversy regarding "Code 3" dispatch began in August, 1991 when Fire Department began dispatching Courtesy "Code 211, rather than Courtesy automatically responding "Code 3" on every incident. The reasoning behind this is that emergency vehicles responding through the City with red lights and sirens pose a safety hazard to pedestrians and vehicles on the street. Since Fire Department emergency medical personnel arrive on scene in four minutes or less on average, there is no need to jeopardize the safety of City streets. This dispatch policy is actually routine for most Fire Departments, including those cities in the :Inland Empire. Courtesy objected and in fact, until the lawsuit judgement came out, ignored Fire Department orders and continued to respond "Code 311 . Numerous studies and reports, including those done by the U.S. Department of Transportation and the National Association of Emergency Medical Services Physicians, indicate that routine use of red lights and sirens represent an unacceptable and preventable safety hazard. c c O O N W d a 0 w O V P U II II II C t Z C N (n O CV) cq x x a � LLI C C �p z a O O +�' C a _ :�• O U U) a0 n0 y w z w I � qt M P. 0 x x z u. G � cr- U WW IF `� H L1) to F W N N N x a: •n � O a. z d v F U z a y r cu C W F W N A z 0 C F W N co Cl) > co Q LLI = = Q J Z W 0 F = Q Q Cc 0 m Q a a L u II u u WUacz d c c o N d LL CY) C II II II c N N r U L L rn W N N O C7 Cr c N X X O '. 0 N >� O O d a . C a z W a d o ° U d CL X X h w z R o N O U Iz CL w LU o U z a H r z a ¢ F U OU vF"i W < W 0 U tl H Q G] N F v N 0 � U zI a F w Q I w 0 U �' F I W _ y a z F. o F y W W Q C/) (J) V)W T- J Q= _ C) Z rn Z W LO 0 J 2 � _Q C`3 m II II II II STATE OF CALIFORNIA—HEALTH AND WELFARE AGE PETE WILSON, Governor EMERGENCY MEDICAL SERVICES AUTHORITY 1930 9TH STREET, SUITE 100 SACRAMENTO, CA 95814-7043 w (916) 322-4336 ` FAX (916) 324.2875 November 22, 1993 t �l't .' ! 1l l Mayor Torn Minor ;-+5r !"� ",s• 300 North D Street San Bernardino, CA 92418 e;� Pn'\Yon Dear Mayor Minor: This is in regards to the current conflict between the City and County of San Bernardino over provision of emergency ambulance services with the City. The dispute between the City and County is now at the appeal stage, but in the meanwhile, an agreement is needed between the parties to ensure the uninterrupted provision of , paramedic services within the City of San Bernardino. The County Emergency Medical Services agency has developed an agreement which it has offered to the City to serve as an interim measure pending resolution of the court process. I understand that, despite the short time frame involved, there has been little or no direct negotiation between the parties. The County has contacted rne, as director of the state agency which has responsibility for oversight of emergency medical services and certification of paramedics, to see whether we can provide some assistance. Without discussing the merits of the original dispute, I think it is important now that an agreement be signed by the parties. If there is no agreement, for one thing, individual paramedic certification will be in jeopardy. There may be no way to ensure that paramedics are performing under medical control. Without this assurance, we would have to look closely at whether paramedics working for a provider within the City without a contract with the local CMS agency are in violation of the terms of their certification. 1 would appreciate an opportunity to meet with you and perhaps be of some assistance in getting this matter resolved. I will call you within the next week or ten days to set up an appointment. in the meantime, if you have any questions, please call me at the above number, extension 332. Sincerely, ( Joseph E. Morales, MD, MPA Director Jr-iui:; JG�':1C5 hi/S H 4GE ✓_12 IL APIk TO: The Mayor and Common Council of the City of San Bernardino FROM: Ronald G. Skipper, Attorney at Law DATE: December 2 , 1993 SUBJECT: Emergency medical services negotiations between the City of San Bernardino and Courtesy Ambulance 3 CC _ U For the past two and one-half (2h) years, an ongoing area of dispute has existed between the City of San Bernardino, which offers emergency paramedic services, and Courtesy Ambulance, which also provides paramedic services within the City limits of San Bernardino. History: In July, 1991, the Fire Department implemented a Paramedic Membership Program that established a fee of $10o - $200 for every medical aid call that the Fire Department responds to within the City. The City contracted with Courtesy Ambulance to provide billing services for us. In August, the Fire Department began to receive complaints from citizens that their insurance companies were not covering the cost of two paramedics on one medical aid call. As staff investigated the complaints, it became apparent that Courtesy Ambulance was charging for paramedic level services, even though the City was the actual provider of those services. Over the next few months, Fire and Administrative staff held a number of meetings with Courtesy Ambulance, the County Health Case Agency, and ICEMA to work out a solution to this "double billing" issue. The position of both the County and Courtesy was that the County controlled all pre-hospital care and Courtesy was authorized under County regulations to staff and bill for paramedic level services on all medical aid calls within San Bernardino. The last meeting was held on November 25, 1993 . On December 10, 1993, the County and ICEMA filed suit against the City for declaratory relief regarding authority over pre-hospital care. Soon afterward, Courtesy joined the lawsuit against the City. Once the lawsuit was filed, the City stopped all negotiations so as not to affect the progress of the suit. On March 29, 1993 , Superior Court Judge E. Michael Kaiser issued a judgment in favor of the City of San Bernardino in County of San Bernardino, et al . , vs. City of San Bernardino, et al. The judgment is on appeal. In essence, the judgment provides that the City of San Bernardino retains control over the administration of all pre-hospital emergency medical services and the County only has authority over medical control. In specifically addressing the issue of ambulance transport, the judgment cited Government Code Sections 38794 and 54980, which expressly authorize cities to 'ao A SF-100 SERIES FAX PAGE 03 The Mayor and Common council of the City of San Bernardino Page Two December 3, 1993 provide ambulance transport and the Emergency Medical Services Act does not expressly or impliedly repeal those government code sections. The final judgment did not specifically authorize the City to provide emergency medical transport, however, a strong inference can be drawn that the City has not been limited by the Judgment. The problem issue, that there are two distinct providers of paramedic services, has yet to be resolved. Citizens in many instances are being charged two separate paramedic charges which can substantially increase ambulance billings. On May 24 , 1993 , the Mayor and Common Council directed the City Administrator and Fire Chief to develop a plan for the provision of City Fire Department emergency transport services and present the plan in a public hearing scheduled for July 19, 1993 . Negotiations between the City of San Bernardino and Courtesy Ambulance failed to arrive at a resolution of the problem. In an effort to resolve the pending dispute between the City and Courtesy Ambulance, both of those entities agreed to have me, Ronald G. Skipper, attorney at law, review all of the pertinent data and meet with representatives of each entity. Several meetings were held and discussions took place to determine if an acceptable middle ground could be arrived at to resolve the matter and/or reach an acceptable proposal which could be submitted to the Mayor and Common Council. It has become evident to me that the positions of the City and Courtesy are so far apart that a meaningful settlement proposal cannot be achieved. Good faith efforts on both sides have not resulted in a resolution of the many issues that are involved in the delivery of and billing for emergency medical services and the development of a written protocol. It was my pleasure to have attempted to be of assistance to the parties in this matter. I am sorry that a resolution of the matter was not achieved.