PRIVATE PROVIDER TACTICS: WHO`S FOOLING WHOM?
BY JEFF RUSTEEN
In 1994, the California Ambulance Association (CAA) sponsored a bill in the California Assembly to change emergency medical services (EMS) operations in California. If passed, the Tucker Bill AB 3156, as it was called, would have tipped the balance toward the private provision of EMS in California.
This occurred as many local fire service jurisdictions were better realizing that a significant portion of their service is the provision of EMS.
The Tucker bill was defeated at the last moment by direct and personal lobbying efforts coordinated through California Professional Firefighters (CPF) and the League of California Cities. Hundreds of firefighters in uniform spent several days in the capital city talking to their legislators. Significant letter-writing and phone-calling campaigns were also necessary. I discovered one thing: Legislators are like computers–if bad or tainted information goes in, bad decisions come out (in the form of legislation).
This was but another “wake-up call” to those public providers who do not see the winds of change blowing!
HISTORY OF CONFLICT
Before EMS was called EMS, ambulance “service” was provided by a confusing mixture of mostly private providers, including funeral parlors, medical supply companies, and physician phone exchanges. Starting mostly in the late `50s and early `60s, pure ambulance “companies” began to show up. Their role was primarily to drive patients to the hospital. During this period, many areas were left “uncovered” or poorly protected; there were few (if any) “professional” managers in the business, competence was minimal, and supervision was scant.
Between the `60s and `70s, more counties and municipalities became involved. Counties began to organize the orderly dispatching of what were becoming the EMS units of that time. Other providers of service, such as police departments, hospitals, and fire departments, also emerged.
Beginning in the mid `70s, consolidation began to occur in the EMS community. In California, Medevac was one of the first “EMS corporations” to emerge. Although initially a multicounty operation, Medevac suffered from the same management problems as its smaller predecessors and eventually disappeared.
Today, we have large private EMS corporations fielding hundreds of units in multiple states. These companies issue stock and are run by professional managers with plentiful resources; they also have the ability to raise significant capital. With this advantage, they are buying up smaller companies faster than the Clinton Administration can say “health care reform.”
These companies have all the things the fire service does not have: We cannot easily raise capital; we operate within a limited budget and with limited personnel resources, we do not concentrate our resources according to call volume or ability to pay; and, for the most part, our managers are not fortunate enough to have business education/experience backgrounds that compare with those of managers in the corporate world.
TIME DIFFERENCES
The concept of protection has not been applied to EMS as it has to police, fire, and hospital services. The public demands access, efficient use of tax dollars, competence, and strategic placement in these public sector services. Resources are designed to meet or exceed normal demand (with short response times).
Applying this same standard to EMS is a concept that is long overdue and that fire executives should consider. Few of us would tolerate many of the response elements pres-
ent in areas where private EMS is the sole provider.
In Alameda County (where I work), there are major response time discrepancies between public and private providers. Fire response averages roughly three to five minutes for fire service ALS (advanced life support), while county-approved times for private contractors are to be within 10 minutes 95 per cent of the time–the average is usually between seven and nine minutes.
How would an eight- to 10-minute response to a structure fire or burglary in progress go over in your community? When service like this comes from police or fire, community groups begin to scream. They do this because they see the results more graphically and have been “sensitized” to this aspect of public service. This is even more true today than in the recent past, due to the large number of programs that showcase public safety services and response.
Considering that the patient`s chance of survival often rests completely on EMS response time, you would expect this area to receive equal attention from the community. However, the public has not been educated. Most residents have no idea that the paramedics who show up are rarely part of the fire department. This is a problem we created and, to this day, do nothing about (in most jurisdictions).
If life safety is our number one priority in fire and other emergencies, why do we allow a group whose primary motive is the bottom line to affect the most important element in medical emergencies–the time it takes to get definitive treatment and transportation? For its own good, the public needs to be informed, through public education, that the fire department can almost always beat the private provider to the scene.
THE STRATEGY OF PRIVATE EMS PROVIDERS
One of the primary strategies of private EMS providers is to appear friendly to local fire service agencies that wish to start ALS operations. ALS transport startup costs can be restrictive, so many municipalities are starting with ALS engine companies. The rationale is that fire service paramedics will get to the scene within three to five minutes, thereby stabilizing the patient and rendering lifesaving care. Minutes later, under no immediate response pressure, private transport arrives to move and bill the patient. If the situation is critical, the private provider may request fire medics to go along for help.
This is great for the patient, who receives prompt care, and the private contractor, whose response time inadequacy is covered by the ALS engine company. If response time is good, the citizens perceive health care in general to be good as well.
On the other hand, it looks bad from the taxpayers` bottom line because it amounts to redundant service and a hidden subsidy for the private provider. Engine companies already go to most, or all, of these calls. Municipal cost is almost the same under this scenario because municipalities still must maintain vehicles, supervision, dispatch, equipment, and personnel for emergency response. The private contractor duplicates the same elements with public tax dollars including, in many cases, “hidden subsidies” and health care dollars–something none of us can afford. In some systems, this allows private contractors to send one paramedic and one EMT1 to emergencies, which significantly lowers the cost of providing the service. In fact, private companies do not have, nor can they muster, the resources required in many out-of-hospital emergencies. They rely on the local agency to provide manpower.
In California, the two largest providers are actively encouraging fire service ALS engines for the above reasons. We do the legwork, begin treatment, package the patient, and provide free manpower to a private, for-profit company; in many cases, all that are left are transport and billing.
VOLUNTEERS, WATCH OUT!
If you think you are beyond reach, consider this: If you operate in a community that pays its bills, and the citizens of that community generally have medical insurance, private contractors will find you. Last year, for example, a private emergency response company with a good record of providing municipal fire and medical response services sent information packets to most (if not all) city managers in California. There was an offer for further information and a presentation for those who were interested.
Companies seeking to privatize municipal services need paying operations to subsidize their losing contracts in areas that they cannot pay their bills or have poor insurance coverage. They will have great difficulty expanding without this support. One tactic that private companies have employed, particularly in areas served by volunteer emergency service agencies, is to keep a percentage of profits; the remainder is turned over to the local governing body for municipal use. This is the tactic used in the county I live in and which has served to insulate the contractor from critics by providing a much-needed source of nontax funds. In areas such as my own, where every municipal body is under increasing fiscal restraint, offers like this look very tempting. You might consider lowering your tax-funded requirements based on income from ALS service as a countermeasure. n
JEFF RUSTEEN is a firefighter/paramedic in the Oakland, California Hills area with 21 years of emergency response experience. He worked for more than 10 years with private EMS providers and held the position of paramedic supervisor. He has also worked for the City and County of San Francisco Department of Public Health Paramedic Division as a paramedic and 911 dispatcher for eight years.
