DEVELOPING FIRE SERVICE/EMS PARTNERSHIPS: IS WAR EEALLY NECESSARY?
BY GORDON M. SACHS
Many fire departments across the country have been faced with the task of developing a plan to increase their operational role in emergency medical services or finding a method to provide timely access for all citizens to emergency medical care and transportation services without increasing costs or decreasing fire protection services. Many options are available. A very feasible alternative would be a public-private or fire/EMS partnership for EMS transportation. However, many agencies have concerns about a partnership arrangement, stemming primarily from the perception of a nationwide “war” between public and private EMS providers portrayed in the professional and trade journals.
While separate articles could be written on theoretical means of improving the efficiency and effectiveness of EMS response or on public/private partnerships, this article examines only the aspect of public-private or fire/EMS partnerships.
PROS AND CONS OF PUBLIC-
PRIVATE PARTNERSHIPS
There is nothing new about the fire service working with a private EMS provider to deliver prehospital care and medical transportation, but the trend toward entering into partnerships seems to be growing. By integrating the fire department`s geographical-deployment and rapid-response capabilities with the private ambulance industry`s transport resources, an efficient and flexible prehospital EMS system can be instituted. Jack Stout, known for developing many EMS systems based around private ambulance services, states, “Just as a reliable private ALS transport system is no substitute for a reliable first-responder program, a reliable first-responder program is no substitute for a reliable ALS transport service. A first-class prehospital care system must have both.”1
Municipalities that use a combination fire/private system have found that such a system can offer greater efficiency, patient care, and cardiac-arrest survival rates. The formation of a public/private partnership can also produce spinoff benefits for the fire service, ambulance companies, and citizens alike. The rapid move of the health care industry toward managed care will necessitate a change in the way prehospital EMS is administered, and a public/private partnership will help ensure an appropriate application of emergency care and transportation in a managed care environment. A partnership between Tualatin (OR) Valley Fire & Rescue and American Medical Response Northwest, for example, has yielded advantages including higher productivity, private business expertise, expanded resources during disasters and severe storms, a re-gional approach to health care that crosses jurisdictional boundaries, and greater accountability to taxpayers and customers.2
From a fire protection standpoint, an EMS partnership arrangement that augments fire company staffing can lower the Insurance Services Office (ISO) fire insurance class ratings. This can reduce the cost of fire insurance premiums on residential and commercial properties. From a political standpoint, a sound partnership arrangement can increase service levels while minimally impacting costs or fire protection. With regard to the “war” between the fire service and “privates,” a partnership can help heal wounds by eliminating costly lawsuits, restoring damaged reputations and providing an avenue for improved relations and service. And, to ensure that all parties are accountable, all aspects of the partnership that a municipality might be concerned with can and should be written into the partnership contract.
A few negative aspects of public/private partnerships have been identified. Field supervision by a private ambulance supervisor provides many important connections to the medical community that might be lost if this supervision is reduced or handed over to a fire suppression supervisor not inclined to pursue these relationships. Similarly, there can be problems with personnel from different agencies working together, such as determining and enforcing who will be in charge at the scene and when a fire department member should “ride in” with the ambulance to the hospital.
SUCCESSFUL PARTNERSHIP MODELS
According to the literature reviewed, several partnership models have been implemented. One such model, being implemented in San Diego, involves the fire department`s providing 911 emergency transportation and a private ambulance company`s providing interfacility and nonemergency transportation. In other locales, the fire department provides the ALS personnel, and the private ambulance company provides transportation resources and access to the reimbursement process. “In most cases, the public agencies that provide ALS services, whether by engine company or ambulance, have a better geographic distribution of resources than the private EMS providers …. On the other hand, the private ambulance companies` use of system status management of their BLS units allows them to provide an almost unlimited availability of transport resources.”3
Another model involves the private ambulance company`s placing a full-time cross-trained/dual-role employee within the fire department for eight hours a day, Monday through Friday. This resource not only improves rapid first-response capabilities but also provides additional manpower for fire suppression.
One area in which fire departments and private ambulance companies can work together is billing and revenue generation. “The drafting of a service contract could assure that authorized ALS fees, collected through ambulance company transport billings, would be forwarded to the fire department. Through such a mechanism, fire departments could generate revenues without encumbering the costs presently related to the fire department patient transportation.”4
Another partnership method uses existing personnel assigned to combination suppression-capable ambulance vehicles for rapid response while contracting with a private company for collections, legal assistance, equipment maintenance, and similar support services. A common alternative involves a partnership where fire departments use an engine company paramedic program with existing personnel to augment the services provided by a private ambulance contractor. In either case, the ambulance contractor could pay a negotiated annual fee or per-run charge to the fire department. These alternatives, which minimally affect fire protection, provide a revenue stream to fire departments, improve the level of service, and politically are the least damaging.
Jim Page, an expert in EMS system design, stated in a presentation at Fire-Rescue International in September 1995, that a nonprofit cooperative, while uncommon, is a good format for a fire service/private EMS partnership. In this type of arrangement, the cooperative could be funded by a subscription program, where the revenue goes into an enterprise fund shared jointly by the fire department and private company.
Three partnership models were described by Alec Jensen, executive officer of Tualatin Valley Fire & Rescue, in a phone interview on April 11, 1997. One model active in Clackamas County, Oregon, has a fire department ambulance activated as a private ambulance resource when the call load reaches a certain level. In return, the fire department receives an annual contracted amount and an ambulance. In a second model, the fire department sells services to any bidder of ambulance services. The services “sold” by the fire department include ALS intervention (to stop the clock, increasing ambulance response time requirements); fire department ambulances entering the system status plan at certain call-load levels; and fire department ambulances transporting during certain critical medical events. In the third model, the fire department is the main provider of transportation service, and other services–including EMS dispatching, billing services, and private ambulances entering the system during certain call-load levels–are “sold” to the fire department. Interfacility ambulance transportation would still be determined through open competition.
OPERATIONAL AREAS FOR CONSIDERATION
The literature shows that nearly any part of EMS can be considered in a partnership arrangement, depending on the needs of the community and the partners involved. Many of the pieces reviewed related to funding. Typical were statements such as, “By integrating the private ambulance company`s billing system into the partnership, access to the reimbursement system for both the first response and transport can be achieved.”5
Another common area was that of dispatch. Some fire departments contract with a private ambulance company to do their EMS dispatching for a small fee per call dispatched. In many other municipalities, the fire department dispatches the private ambulances, often for a fee.
When more than one agency are involved in the delivery of EMS, the quality of service and continuity of care depend on joint in-service training, standard protocols, uniform medical control, and standardized equipment. According to Stout, “Where cooperation is valued, solutions are found. Elsewhere, solutions are impossible.”6
Trace Skeen, CEO of American Medical Response Northwest, has lectured on public/private partnerships and developed the following list of components of a cooperative working agreement:
Integrated telecommunications capabilities;
Coordinated data retrieval and utilization reports;
Shared quarters;
Training provided by the ambulance contractor, i.e.,
–supervisory skills and leadership development,
–EMS skills enhancement program, and
–ongoing training and evaluation program;
Training provided by the fire department, i.e.,
–incident command system training,
–rescue and extrication,
–haz-mat recognition and management, and
–complex mapping and training;
Coordinated recruiting;
Standardized equipment utilization;
Equipment retrieval; and
Community education programs.7
Many fire departments across the country have been faced with the task of developing a plan to increase their operational role or capabilities in emergency medical services without increasing taxes. In an effort to do this, Marion County Fire-Rescue (MCFR), Monroe Regional Medical Center Ambulance Service (MRMC), and the Ocala (FL) Fire Department jointly purchased an emergency medical service disaster response trailer.
Similarly, the three agencies, with the cooperation of the Florida Department of Health and Rehabilitative Services Office of EMS, opened a joint EMS training facility. MCFR and MRMC continue to operate the joint EMS training facility. This has spawned cooperative communications projects, joint biohazardous waste disposal and equipment disinfection practices, shared medical control and direction, and other similar efforts.
MCFR and MRMC are in the midst of implementing a more involved fire/EMS partnership. In essence, MCFR will augment MRMC`s current ALS transport capabilities in some of the rural areas of the county where MCFR now provides only nontransport first response. MCFR is placing in service two transport-capable fire-rescue units, equipped and licensed for patient care/transportation and equipped with a 200-gallon water tank, 250-gpm pump with Class A foam system, and basic firefighting. Six dual-certified paramedic/firefighters will be hired; MRMC will pay the cost of salary and benefits as well as one-half the cost of fuel and maintenance for these new units. This partnership will decrease ambulance response times, increase staffing at two fire stations, and increase fire protection capabilities–all without significantly affecting the cost of service.
DEVELOPING A PARTNERSHIP
Much of the literature identified areas of importance when developing partnerships. “A rational approach at providing stable service for the citizens can produce a solution which will benefit both ambulance companies and the fire service along with the end user of the service, the injured or ill citizens.”8 In other words, the efforts must be undertaken by focusing on the desired outcomes–better service for the citizens being protected. This approach must begin with the long-term commitment of the leadership of the fire service and ambulance company. The private ambulance company may also need an incentive to participate, such as an increased level of service or decreased operating costs.
Another common theme among the literature was that the development of a fire/EMS partnership would be a significant operational or organizational change. The National Fire Academy resident course, “Strategic Management of Change,” comprehensively discusses the “change management model,” a process for managing change in an emergency service organization. It is important that a community begin by putting together a committee to study the issues involved in that jurisdiction. The committee should have representatives of all organizations with an interest in the EMS program, as well as personnel in both departments who may have knowledge or expertise in appropriate areas.
Some systems have used consultants to develop a Request for Proposal for a partnership, and some have used public hearings in which interested parties (citizens and businesses alike) were allowed to comment and provide input. Teamwork and cooperation between the fire chief and the members, and between the fire department and the public, are critical components of successful change in the development of a partnership plan. The effects of internal and external resistance were also identified as a concern. “Overcoming internal resistance to the new program and communicating the change to the public is absolutely essential to its success. Making the public and fire department employees partners in the success of the EMS delivery system will greatly enhance your chances and limit the risk of failure.”9
The importance of a strong relationship with the media was also discussed. This separate partnership with the media can make or break a budding fire/EMS partnership, as public opinion is often shaped by the media. This media relationship must be shared equally by the fire department and the private EMS provider. Skeen summarized this point by commenting on his experience, “While the resources varied slightly between agencies, we discovered that open dialogue developed into a high degree of cooperation and a healthy dose of enthusiasm ….”10
* * *
There are many “pros” of a public-private partnership in EMS, as well as a few “cons.” Partnerships in EMS are not new; some municipalities have been successfully involved in fire/EMS partnerships for many years. The formation of a public/private partnership can produce spinoff benefits as well, including higher productivity, expanded resources, and greater accountability to taxpayers and customers. The changing health care culture–the influence of managed care, for instance–also creates more of a need for fire/EMS partnerships.
Operational areas to be considered are numerous but depend on the needs of the community formulating the partnership. As described in the numerous partnership models identified, these areas range from administrative to tactical. Funding, training, dispatch, protocols, and medical control/medical direction were commonly discussed in the literature as partnership areas.
The fire department and EMS leaders` motivation, commitment, and knowledge of and appreciation for the strategic management of change are prime considerations in the development of a successful partnership. The use of the National Fire Academy`s “change management model” or a similar use of a representative committee should be employed, and the hiring of an expert or consultant to assist in the development of the partnership plan should be considered. Personnel are an important consideration in all successful partnerships. This fact should not be overlooked. Finally, the importance of a strong relationship with the media and positive effect of marketing the partnership must be considered.
Many factors need to be considered when developing a fire/EMS partnership, the most important of which involves identifying the areas that would be best served with a partnership, as they will be different in every community. Reviewing several different successful partnerships can provide insight into the possibilities; following recognized change management models can enhance the likelihood of success and minimize the chances of sabotage or insurrection.
The concerns about a partnership arrangement can be addressed through the identification of many successful partnership arrangements. Partnerships between fire departments and private EMS agencies can be innovative and should prove to be a “win-win-win” effort. In addition to increasing the capabilities of the fire department and decreasing costs for the ambulance service, the real benefactors of a partnership will be the citizens in the affected areas. n
References
1. Stout, Jack. “Fire vs. Private EMS: It Doesn`t Have to Be This Way.” JEMS, June 1987, 84.
2. “The Right Choice for All the Right Reasons,” flier from Tualatin Valley (OR) Fire & Rescue and American Medical Response Northwest, 1996.
3. Lawrence, Peter, “Partnership Includes Revenue Sharing, Fire Chief, Dec. 1995, 20.
4. Appel, George B. A Partnership in Ambulance Transportation: A Fire Service Paradigm Shift. Executive Fire Officer Program Applied Research Project, National Fire Academy, Emmitsburg, Md., 1995, 15.
5. Lawrence, 20.
6. Stout, 85.
7. Skeen, D. Trace. “Public/Private Partnership: Myth or Reality?” Firefighter`s News, Nov. 1993, 60.
8. Appel, 2.
9. Waters, Robert J. Successful Organizational Change Within the Fire Service: Integrating an EMS Program into the Operational Plan of a Fire Department. Executive Fire Officer Program Applied Research Project, 1994, 19.
10. Skeen.
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The MCFR/MRMC/OFD EMS disaster response trailer. (Photos by author.)
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Sign at the entrance of the MCFR/MRMC/OFD joint EMS training facility.
n GORDON M. SACHS is chief of the Training/Safety Division of Marion County (FL) Fire-Rescue. He has more than 19 years of fire and EMS experience in both the career and volunteer services. In addition to many journal articles and U.S. Fire Administration publications, Sachs wrote the EMS chapter in The Fire Chief`s Handbook, Fifth Edition (Fire Engineering Books, 1995). He is a National Fire Academy instructor in both EMS management and health and safety. Sachs currently chairs the Florida State Fire College EMS Management Curriculum Advisory Committee and is a member of the Fire Engineering editorial advisory board.
