EMERGENCY MEDICAL SERVICES

Roundtable

Emergency Medical ServiceS! These three words have changed the face of many “fire” departments across the United States over the past 50 years. Most departments respond to some form of emergency medical services (EMS) runs on a daily basis. Only a handful of departments that make no EMS runs exist today.

The Toledo Fire Department (as it was called then) recorded its first EMS runs in the early 1940s. When my father joined the department in 1952, only the “rescue squads” made EMS runs. When he was assigned to #1 Squad in 1955, private ambulances or the police (in paddy wagons) transported the ill or injured to hospitals. In 1954, Toledo responded to 2,723 EMS runs. The fire department collected no money for these “first-aid” runs.

When I came on the job in 1975, all engine and squad companies made EMS runs. We responded to just a few more than 14,000 EMS runs that year and only slightly more than 9,000 fire runs. By this time, advanced life support (ALS) units were running in Toledo (two units staffed by fire department personnel) along with the first responders. Private ambulances transported the basic life support (BLS) patients.

Today, approximately 80 percent of our runs (45,000) are EMS. We now have five ALS life squads. Two ALS engine companies and trucks now make EMS runs when necessary. [We are looking at running all engines (17) as ALS engines this year.] Even our name has been changed to the Toledo Department of Fire and Rescue Operations to reflect our “commitment” to EMS.

We currently do not charge for any of our “emergency” services. We have looked at several options but have not yet focused in on any one charge-back system. We do charge for “standbys” at special events and now can recoup some of our expenses at haz-mat runs. I believe that within the next five years, some new system (whatever that would look like) will be in place.

-John (Skip) Coleman, deputy chief of operations, Toledo (OH) Department of Fire and Rescue; author of Incident Management for the Street-Smart Fire Officer (Fire Engineering, 1997); editorial advisory board member of Fire Engineering; and member of the FDIC Educational Committee.

Question:

With emergency medical services demanding so much time and resources in today’s fire service, there has been a trend toward “EMS for Profit” in many departments. Has this “charge for services” policy hit your department? If so, to what extent?

Bob Oliphant, lieutenant,
Kalamazoo (MI) Department of
Public Safety

Response:

At present, we provide basic life support services at no cost. A private ambulance company operating under a municipal contract provides ALS services and charges for services and transport. At one time, the department provided ALS services at no cost but did not transport. After being treated, the person would be handed over to a private ambulance pro-vider, who charged for transport. This was done to avoid complaints that a tax-funded entity was competing unfairly with private enterprise. It was a good deal for the ambulance company, but not for us. When money became tight and it did not appear that citizens would pay extra for ALS services, it was given to a private contract company.

As long as there are private companies capable of providing ALS services and transport, I don’t see us trying to compete with them. I don’t think we could do it cheaper or provide better service. The tax-funded entity vs. private-enterprise issue is still a barrier. Interestingly, our current model of emergency medical response was adopted from a municipality that is now trying to get back into EMS for profit.

Gary P. Morris, deputy chief,
Phoenix (AZ) Fire Department

Response:

The Phoenix Fire Department does not charge a fee for “general” EMS services rendered “on the street.” In other words, if a patient is treated by EMTs or paramedics at an accident scene and chooses to refuse ambulance transportation or other care, no charge for services applies.

The department, however, has operated a BLS ambulance transport service with cross-trained EMT firefighters since 1985. This service charges various fees for transportation and other services rendered. For ALS transport (ALS treatment has been initiated and a paramedic from an ALS engine is in attendance), the transport fee is $385.46. The fee for a BLS transport is $287.59. Other charges include a mileage rate fee and costs for supplies, medications, and some treatment services that may be rendered.

All fees are regulated by the Arizona Department of Health Services. Revenues obtained from the transport system billing are used to support the system.

As a side note, the ambulance transport system has proven to be a real asset in the department’s compliance with the OSHA two-in/two-out rule. For years, we have included an ambulance as part of structural dispatch assignments to reported structure fires. They are two-member firefighter teams that often arrive with, or very shortly after, the first-due company. As a result, they are assigned the “out team” duties. This use would be a marketing tool for fire departments seeking to assume their community’s EMS transport service.

Thomas K. Freeman, fire chief,
Lisle Woodridge (IL) Fire District

Response:

Our department is not unlike many fire department-based EMS providers. We provide full-service ALS throughout the district. Calls for emergency medical services account for 50 percent of the activity in the district. The fire district’s revenue stream depends heavily on property taxes. Additionally compounding this revenue source is a property tax limitation law that restricts annual increases to five percent, or the Consumer Price Index-Urban (CPI-U)-whichever is less, plus new growth. Last year, the CPI-U limitation for our county was 1.6 percent.

In essence, the effect of the state-imposed limitation factor was an auto-erosion of the fire tax rate extended to the residents of the fire district. All the while, we are faced with the continued concern of diminished resources as a result of reduced local government priority.

As a result, new and creative alternative revenue sources are a necessity. With an increase in calls for EMS and a need to deliver more diverse services as demands for those services shift, the need to impose benefit-based billing becomes a reality. Those who benefit should pay for the service at the risk of reducing levels of EMS or other vital programs to the community should service expenses escalate beyond revenues.

To that end, anyone receiving EMS in our district, resident or nonresident, receives an invoice for services and treatment delivered. Benefit-based charges are assessed using a base rate for transport and additional fees for specific procedures.

The prospect of paying user fees for services typically made available as a function of paying taxes is not popular. The myriad menu provided by the fire service has brought us to this crossroad. Therefore, why not pass on the cost of doing business to the end-user? The emergency medical services are made available by virtue of the taxes levied. However, once delivered, additional costs must be recovered, otherwise the distasteful option of increased taxes for all must be broached. That said, why should all pay for the provision of a service or program only some use? In a fire district, this is analogous to paying taxes to school districts and paying tuition and related fees only when your children attend school or paying for the park district and having a surcharge levied when you use the pool or some other amenity.

Certainly, for fire departments and districts providing EMS transport, the issue of charging for service is in the forefront, as well it should be. And reimbursement is not limited to only this facet of our program delivery. As fire chiefs, we must ensure that we provide the highest quality of service in a profession that nobody does better than we do. As administrators, we must ensure that we provide that service in the most fiscally responsible manner. Alternative revenue, vis-

Larry Anderson, deputy chief,
Dallas (TX) Fire Department

Response:

Our department has operated the city’s EMS system since 1972. The fee per transport at that time was $25. It was increased incrementally until 1993, when we went to itemized billing. Today, our average transport fee is $331 with a base rate of $241 plus itemization. The EMS budget is approximately $20 million per year, of which we collect slightly more than $7 million per year. We use a third-party company to assist with bill collection and are collecting about 40 percent of transport charges. The citizens are generally pleased with the service we provide and seem willing to pay for that service partially with tax dollars. In light of the aforementioned statistics, it is obvious we are not “for profit” when it comes to EMS.

Ronald Hiraki, chief of training
Seattle (WA) Fire Department

Response:

The Seattle Fire Department responds to ALS and BLS incidents. ALS patients are treated and transported by Seattle Fire Department firefighter/paramedics. BLS patients are treated by firefighter/ EMTs. When transportation must be expedited, the department’s BLS unit may transport-for example, if the patient is lying on the rain-covered street or if it would be unreasonable to wait five more minutes for a private ambulance, then the BLS unit will transport. The aforementioned services are provided without charge. When BLS transportation is not urgent, a private ambulance is called to continue treatment and transport the patient to the hospital. The private ambulance company charges the patient.

Several years ago, a county levy to fund EMS failed. This prompted discussion and a proposal for the department to charge for ALS treatment and transportation. The intent was not to make a profit but to ensure funding and ask users to pay for the services used. The medical community, firefighters, and citizen groups strongly opposed this approach. Some of the arguments used in opposition were the following: Charging for services would inhibit people from calling for help, firefighters would be viewed as selling instead of providing services, and citizens who had generously supported the funding of EMS for many years might reconsider their support if charged for services. The discussion ended with no action taken toward charging for EMS.

During the past two years, our department has considered providing BLS transportation for a fee. This would require adding additional BLS transport units and firefighter/EMTs. We could eliminate the need to rely on a private ambulance company, thereby stabilizing and improving response times. Because this additional service would not be profit-oriented, and since some of the infrastructure is in place, the department believes that it could provide BLS transport at a lower cost than a private company. There is opposition to this plan as well, for reasons similar to those expressed regarding charging for ALS transport.

Our goal is to stabilize, maintain, and improve the quality of EMS-not to make EMS a profit-making venture. We would not want to profit from someone’s emergency. The increased demands for EMS and our customers’ needs necessitate that the department investigate all avenues of providing consistent funding and improved service.

Rick Lasky, chief,
Coeur d’Alene (ID) Fire Department

Response:

The EMS system for our area has undergone some significant changes this past year. Up until recently, the county administration managed the EMS system for Kootenai County and had operated in the following way:

  • Most of the fire departments responded to EMS calls as first responders.

    A single paramedic in a sport utility vehicle responded to those calls Central Dispatch determined to be ALS in nature at the time of dispatch. The paramedics were county employees and were housed in and responded from the area hospital. In most cases, if the paramedic provided ALS treatment, he would need to park and lock his vehicle at the scene, delaying getting back in service, or would have to have one of the first responders drive it back to the hospital.

  • In our area, transportation was provided by a private ambulance service, Arrow Ambulance/Rural Metro. Nonprofit, volunteer ambulance providers serviced other areas within the county.

  • The transporting ambulance billed patients. If the paramedic provided ALS treatment, a second bill for supplies was sent.

    In an effort to identify problems and areas of service that were lacking, a study was made of the EMS system. It was recommended that a fire-based EMS delivery system be created in an attempt to bring together some of the more fragmented EMS service organizations. With that in mind, three fire districts proposed a system run by the fire service. A joint-powers board was established and an action plan was developed; the county commissioners accepted the proposal.

    The newly formed joint-powers board was given the lead and contracted to manage the system taking on current county employees. On February 1, 1999, the new system went into service and is currently in place. It is operated in the following manner:

  • The fire departments are running as first responders on all EMS runs and are in the process of raising certification levels from EMT Basic to Intermediate.

    The paramedics are still operating in the same fashion but are now employees of the new system. At present, housing and running procedures are being evaluated to determine if there are any weaknesses.

  • Ambulances staffed by EMTs and firefighters of the new system have replaced the Rural Metro private ambulance service, and use of the nonprofit volunteer ambulance services still remains. The volunteer ambulance providers have given and continue to give very good care and dependable service. On the new system’s first day of operation, Rural Metro closed its doors and left the area.

    Billing is now handled primarily by the new system in conjunction with the nonprofit ambulance providers. Along with responding to 911 EMS calls, the new system has taken on the challenge of handling the nonemergency “Net” interfacility requests and bills for those responses as well.

    With what appears to be at least half of our workload-almost 80 percent in some areas-we have to take a more proactive role in providing EMS. Private ambulance services have come and gone, living and dying by the profit they generate. The fire service has always set as its priority providing the best care possible, and then it looks for a way to fund it. Looking for alternative ways to fund all of our programs is becoming more and more of a necessity as we continue to provide quality service.

    Frank C. Schaper, chief,
    St. Charles (MO) Fire Department

    Response:

    The St. Charles Fire Department has been operating an EMS system since 1974. Currently, we operate two life support vehicle (LSV) ambulances and three LSV engines. Our other two engines are equipped for LSV operations and are staffed as personnel availability allows.

    Originally, the service charged a nominal fee to avoid the “taxi cab” runs. Charges have increased over the years and just this past year were raised to conform with the metro area. Depending how one looks at the service determines if it is run at a profit or a loss. My understanding is that the operation was never expected to make a profit and today operates at a break-even pace. However, since our medics are also firefighters and are dispatched on suppression calls, our department gets more bang for the buck out of these personnel.

    The citizens and local government support our EMS. With that in mind, one might say the system is run at a profit. However, all money generated goes directly into the general city fund, not to the fire department.

    Jim Murtagh, deputy chief,
    Fire Department of New York

    Response:

    FDNY is a multitasked service provider to New York City citizens and visitors. EMS is one of the services provided for those in need. FDNY is a public agency-not for profit-and provides the bulk of its services without charge. However, part of the costs are recovered in several areas. Transporting the injured is one of those areas.

    READERS COMMENT . . .

    EMS

    William Shouldis, deputy chief,
    Philadelphia (PA) Fire Department

    Response:
    In Philadelphia, EMS is part of the fire department. Medic units run from fire stations and provide BLS/ALS treatment and transportation. An EMT works on each engine and ladder company so that the fire department is always fully capable of responding on medical assignments. Engine and ladder companies are commonly used to stabilize situations until a medic unit arrives.

    Fire suppression and EMS operations are funded through a single budget. There has never been a third service, but numerous private “for profit” ambulance companies provide nonemergency hospital transport. Approximately 12 years ago, in an effort to improve our prehospital care, the fire department began to “charge for EMS” (medical treatment, supplies, and transportation, for example). This EMS fee was economically driven. All city services needed to be “shored up” because of a dwindling city budget.

    The United States Census provided valuable insight for establishing the department’s strategic plan. Data showed a bleak long-term forecast. The trend in most northeastern cities was a decrease in population. Philadelphia lost almost 20 percent of its residents between 1950 and 1990. The forecast for the city was that the population would get older and poorer.

    Prior to starting the “charges for EMS” program, the chief was very active in the community. His message was concise and clear. Fire department services would decrease, and response time would increase; a user fee would be necessary to offset some costs. In the early months of the endeavor, the media took an interest in the program’s progress. They were seeking a “big story,” even though the fire chief announced that no needy person would be denied prehospital care based on inability to pay. Many older citizens feared the fire department’s new position. The chief’s attitude and candor silenced many of the potential critics who believed local taxes should cover all public safety services. Slowly, the fire department’s fee came to be seen as justifiable. No one wanted to see fire stations closed or the number of medic units decreased.

    The program has had several positive results. Objectively, the number of medic units has increased from 24 to 36 units. Response time has decreased even though the city has experienced an increase in medical emergencies. At this time the city averages approximately 40 calls per hour during peak periods (noon to 3 p.m. weekdays). When Hurricane Floyd struck in September, our dispatch center transmitted more than 1,000 incidents for the day. Today, we have only three BLS units and hope to have a full ALS system within the next year. Subjectively, the fire department seems to get more respect from the elected officials and civic leaders because it is truly a revenue-generating agency.

    At this time, the EMS division is certainly not a profitable venture. We are getting nearer to the “break-even” point. We are not likely to make a profit for humanistic reasons. Our collection agency, which is a private contractor, does not badger people who fail to pay because of inadequate health coverage. However, in reality, most residents and visitors to the city have at least Medicare. We have found that this federal program, after proper documentation by EMS, reimburses 80 percent of the cost. This is revenue the city never attempted to collect until the mid-1980s.

    EMS is an expensive undertaking (training, equipment, staffing), but the mission of a fire department is to save lives. A fire department-based EMS system will accomplish that goal better than any private corporation.

    Two-In/Two-Out Rule

    Bill Hopson, captain,
    Beachwood (NJ) Fire Company

    Response:
    In a volunteer fire department there are times when we are not sure which of our members will be responding to any one particular call. Given this situation, we have made individual firefighter safety a priority in our company. When OSHA came down with the two-in/two-out ruling, we actually welcomed a federal regulation in writing, since we have been following this practice for some time. Thus, the OSHA regulation has not hurt us in any respect.

    Additionally, it has reinforced in our supervisors (line officers) the necessity for looking at the number of personnel responding on each individual apparatus and making an incident action plan that provides for the mitigation of the hazard and the safety of the personnel who are involved in that plan. In short, we are more efficient at managing our personnel on the scene, and we are training our personnel at a higher level than ever before.

    In those instances where the issue of immediate life safety was involved, we have yet to find that one individual firefighter has had to go it alone when entering a building. We attribute this to our training in which we stress teamwork and making sure that members stay in the units to which they are assigned.

    Along with two-in/two-out, we have augmented our FAST team training. Thus, many members are trained in firefighter and civilian removal techniques. Almost all of these techniques require a minimum of two people. Thus, we again achieve the objective of that rule.

    The rule has become part of our standard operating procedures, and our supervisors know that adhering to the SOP is a priority. In this instance, we have embraced the intent of the rule and have enhanced the practice of the rule. We also train on the rule.

    We firmly believe “the way you train is the way you play.” By training with the rules, and not violating them, we feel we should be a more efficient and effective fire company. Since we are not a combination department and we have the ability to request additional personnel from surrounding companies in a relatively short time, we are able to coordinate our personnel better at the point of attack and manage them more effectively because we are trained to do so.

    In our situation, we believe the two-in/two-out rule is one of the few federal regulations that has helped, in comparison to those regulations that compel us to change specific items that have been effective in the past. Our company is progressive and places a priority on individual firefighter safety. Hopefully, this rule ultimately will lead to a long and effective tenure for each of our members.

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