How to provide Austin with higher quality emergency medical response and better overall services at HALF THE COST to the TAXPAYER!

 Open Letter to the City of Austin Council and Executive Management

I have offered my opinion before on how to provide our community with higher quality emergency medical response and better overall services at half the cost.  I’d like to offer another consideration along the same theme but it offers even better outcomes than what was suggested earlier in reconfiguring EMS response for the City of Austin. 

There are three countywide and one tri-county EMS system (similar demographics to the City of Austin) that would be worth looking at as an alternative to the present configuration used by the City of Austin.  Their approach provides their communities with faster response, better quality pre-hospital medicine and at NO TAXPAYER SUBSIDY. For one of the systems it also provides funding (at no taxpayer expense) for AEDs for ALL law enforcement vehicles (police and sheriff) that are now part of the countywide first response network.  It is an extraordinary approach to building a viable and high quality EMS system and worth your time and attention given the potential it could offer in saving tax dollars and dramatically improving EMS services. 

The four “systems” are Portland, Oregon (a three county system), San Mateo County, California, Solano County, California, and Contra Costa County, California.  Each of these county operations have similar demographics to Austin. 

Each “system” is a combination public/private configuration.  The public side of the system is fire based paramedic first responders, and the private side an ambulance transport vendor.  What is so fascinating about their approach is that all of the governments “bid” out the “rights” to provide countywide ambulance service.  The ambulance vendor “pays” each county fees for the exclusive franchise rights for 9-1-1 transport services.  For example, in the Portland EMS System, one of the three participating county’s is Washington County, and they receive over $424,000 a year in franchise fee for this exclusivity (and that is just one of the three county’s for the Portland EMS System).  The money the private vendor pays for the “rights” to serve a county are typically used by the county to fund its EMS oversight operation and system medical direction.  All of this is under a very sophisticated performance contract which stipulates response times by geo-zones (urban-8 minutes, rural-11 minutes, frontier-30 minutes) at 90% or greater performance compliance, regulates the fee structure patients can be charged for transport services, vehicle requirements, employee compensation minimums, including benefits, work conditions, etc.   Not only are their response standards more rigorous than what the City of Austin requires from its own EMS Department but their basic fee structure for services are equivalent to user fee's charged by the City EMS Department for its services. It is also worth noting, the salary a 6 year private paramedic earns in this "system" averages $64,000, not including overtime.  They work 8 & 12 hours shifts.  You will find this competitive to what Austin pays its municipal ambulance paramedic. 

What makes this approach even more attractive for a city like Austin is its existing franchise process for non-emergency ambulance transports.   The city could easily and profitably offer to grant exclusive emergency and non-emergency services to a single private ambulance vendor based on “highest” bid basis.  The profitability of that offering would be very attractive to any well-managed and professional run private ambulance vendor.  The potential savings in taxpayer dollars could be enormous even though a portion of the savings in EMS costs would have to be reinvested in the enhancement of Austin Fire Department first response medical capability it would still offer taxpayer savings for other much needed city projects. Not only would the city get a more reliable and higher quality ambulance response network (at no cost to the city) but an expanded and enhanced fire first response that would dramatically improve the ability to get a first responder paramedic to the side of a patient in 6 minutes or less, all at a cost substantially less than what the City pays now for its ambulance operation.  It would also solve the 4 person staffing issue for Austin Fire and resolve the concern about the added staffing cost being without merit or benefit.  Adding paramedic capacity (or EMT-intermediate in certain cases) to the 4^th position offers unquestionable benefit because of its dual productivity: fire-fighting and paramedic.  The key difference is the cost for this additional duty is an annual stipend of $7,500.  Contrast that to the annual salary of a tenured EMS paramedic who does only one job: $65,000, not including overtime.  The fire-fighter-paramedic is substantially cheaper, gets to the scene faster and offers better quality medicine because time to scene matters in life-threatening emergencies.

Even if you back out the user fee’s the City EMS Department claims offsets 50% of its operational cost, the net cost to city taxpayers is still over $15,000,000 a year.  Contrast the Austin EMS System with these no subsidy high performance EMS systems and its very clear Austin is getting short changed… by about $15,000,000 a year… and that amount will only grow each year.

Ambulance transport is a profit center under the private ambulance model, and a loss leader (big one at that) under government simply because government cannot work at the same pace and under the same private protections the private business can.  Government has special rules that offer the public protection from unethical Tammany Hall practices but they play havoc on its ability to act as a business enterprise.  

The rule of thumb for good government is if the area of service is already efficiently provided by the private sector, its best to let that portion of services fall under private service contract using best practices and a well-written performance contract.   

Government does best in the high risk or regulatory, no profit center areas of service like fire fighting, rescue, medical first response and law enforcement or other regulatory services.  

 Ambulance transport operations, in urban areas like Austin, would be better managed under a performance contract with a well qualified, ambulance contractor. 

When Austin got into ambulance transport no such private solution existed, at least not in this state, but after 30 years a lot has changed.  The private ambulance industry has evolved into a highly refined service operation that offers better services (transporting from point A to B)  and, under the right contract configuration (performance contracting),  can provide those services to a government without a taxpayer subsidy.

By shifting the role of government from a very expensive, subsidy based ambulance transport program with terrible performance, to a rapid response paramedic first response (fire medics on Austin Fire Department apparatus) you reduce the time to a life-threatening emergency from the current 10-12 minutes to an average 5-6 minute or less response time  (50-60% faster).  Plus the cost for outfitting a first response vehicle with equipment and trained fire-fighter medics is around $150,000 per vehicle, about 1/10^th the cost of an ambulance. If transport is required, the private contractor provides those services under a very structured performance contract and all cost for these services are paid for as noted by user fees.  Its win-win for all involved. Taxpayers get better emergent service and the cost savings can, in turn, be used to improve fire services, police services, parks, libraries, etc.   

It is also worth noting the City could still retain some of its ambulance operation specific to the high priority acutely critical calls, all other lower priority call types would be managed by referral to the private ambulance contractor.  My point is that the City continues to support a public safety program that is no longer meeting its base mission and has become a huge drain on public safety funding, and will continue to do so.  There are better, faster, cheaper options that deliver exceptional performance at much cheaper costs to the taxpayer, example: Seattle, a highly respected fire based operation, clinically sophisticated and provides exceptional emergency medical services to its residents.  Seattle uses a public/private model.  The fire department operates a small fleet of critical care "medic" units for the critical call types and paramedic first response engines, supplemented by a private ambulance provider to manage transports for the lower priority call types.  The quality of Seattle's fire paramedics provide clinical care far and above what Austin's EMS operation offers.  

Before I close, one question that will undoubtedly be raised is what happens to the existing city EMS ambulance staff?  The short answer is they would be integrated into the fire department, trained as fire-fighters.  Those who could not meet the physical qualifications or would prefer not to “fight fires” as a secondary role, could be grandfathered into a transition status under their existing salary structure, and operate the fire departments critical care ambulances I mentioned above.  As those individuals retired or left for other career reasons, their positions would be absorbed into the fire ops side.  The initial cost savings for the city would be in eliminating all the duplications in management, logistics, and the reduction in required ambulances.  With the potential for 44+ paramedic first response vehicles, you don’t need as many ambulances, and as ambulance paramedics are transitioned over to fire-fighting, the ambulances they staffed could be shifted to the private ambulance vendor. It also offers the benefit and cost savings of eliminating the currently proposed EMS civil service option with all its layers of expensive and redundant bureaucracy which only adds to the complexity and overall cost of union negotiations for public safety. 

I will be happy to offer you RFP’s used by these counties to select their ambulance vendors, including a full description of performance requirements if you are interested.   They offer great background on how they operate and will shed some interesting light on how Austin could also operate.

Below are some contact references you or your staff can use to verify what I am offering.  All but one is specific to Washington County (Portland EMS System).  Feel free to grill them on their operation; I am betting you will find all are very candid and forthcoming. 

 

Metro West Ambulance-Washington County Ambulance Contractor

Larry Boxman            Director of Operations       

503-648-6658         

larryb@metrowest.fm  

Washington County (Portland EMS System)

Jonathan Chin         EMS Administrative Supervisor- Washington County

971-226-4507

503-846-4956

jonathan_chin@co.washington.or.us

Tualatin Valley Fire Rescue-Washington County

MarK Stevens           EMS Batt Chief- Tualatin Valley Fire Rescue

503-649-8577

mark.stevens@tvfr.com

Abaris Group EMS Consultants-Developed RFP for Portland EMS System

Mike Williams           President

mwilliams@abarisgroup.com

Hope this helps.  If you would like more info, I’ll be happy to visit with you. 

Gordon Bergh

Retired (2006) City of Austin- Assistant Director-EMS
Small Business Owner