Why Travis County Residents Are Poorly Served By Travis County’s Inter-Local for Ambulance Service with the City of Austin

The current EMS inter-local between the Travis County and the City of Austin does not serve the Travis County taxpayer or most importantly the patient.

The average response time for a City of Austin ambulance IN Travis County is over 16 minutes!  In a life-threatening emergency, brain cells begin to die after 4 minutes, and after 6 minutes, the potential for successful resuscitation falls to the single digits.  Those County residents who do get pulled back from the brink of death do so not because of the ambulance but because of the local fire department fire fighters who respond to these calls and the air rescue services provided by Travis County’s STARFlight helicopters.   For this extraordinarily bad performance Travis County forks over an amazing amount of taxpayer money (over $12,500,000) with virtually no control over the services provided.  Even worse, the inter-local does not allow Travis County to utilize existing qualified area fire department resources to mange cost of service and improves response time.  The inter-local offers only a City of Austin solution at a whopping $1.5 million dollars per ambulance and for 2013, the City is proposing another hefty $4,500,000 increase in its cost for services (33% increase)!   To fully appreciate the problem, Travis County could pay to put dual role fire-fighter paramedics on EVERY fire truck in Travis County, maintain higher training quality under a contract with Seton and the UT medical school than the City’s ambulance medics receive under their in-house program and have their own medical director with far more active and transparent oversight of paramedic performance than the City ambulance medical director provides to the County fire department EMT's now, for $4,050,000 ($450,000 less than what the City is proposing for just 4 ambulances and it would reduce response times from 16 minutes to under 8 for county suburban areas and under 12 minutes for rural areas.   The three proposed City of Austin ambulances would improve response times by only about 1-1.5 minutes.  Of course, Travis County doesn't need all its fire apparatus staffed with a paramedic, my point is to simply illustrate how a more common sense approach in delivering EMS can save lots of taxpayer dollars and dramatically improve response time AND capacity.  Travis County needs to do what is right for the patient AND its taxpayers by fixing the existing contract issues with the City of Austin.    

Where’s the Problem?

The City/County Inter-Local has no substantive performance requirements for EMS services other than vague references, my favorite: “ provide emergency medical services in accordance with recognized standards to access, triage, treat, evacuate and transport patients in the most timely manner possible” (and which standards would those be?). 

Additionally, it provides:

• no direct financial controls,
• no accounting of direct services costs by ambulance management,
• no managerial accountability of any type, and
• no transparency in any phase of the services provided

In fact, this inter-local essentially requires Travis County to sign away its contractual "rights" for ambulance contract oversight under the assumption an "EMS system" approach through a inter-governmental partnership provides the county with maximum benefit. 

Unfortunately, what may have provided maximum benefit 25 or even 15 years ago is no longer the case given other cheaper, faster, higher quality EMS delivery options. It essentially relegates Travis County to the role of contractual hostage to a City of Austin managed ambulance service where County needs are always second to those of the City. 

What makes this even more amazing is this particular inter-local agreement has been going on for 25 years, but it has:

·      Never been Independently audited,

·      Never competitively bid  

·      Consistently delivers mediocre to poor service for county residents (and I happen to be one of those) at an extraordinarily high cost for those services 

Violates Core Tenets of Responsible EMS Contracting

This City/County EMS inter-local agreement VIOLATES EVERY CORE TENET of responsible EMS contracting (Ref: The American Ambulance Associations Guidebook- Best Practices in Designing, Managing and Contracting for Emergency Ambulance Service).  

What’s so revealing in this quoted reference is it represents the gold standard for the private ambulance industry inter-governmental contracting.   Typically governments have higher performance standards than private industry for matters of public safety, but for the City/County EMS inter-local, there are no standards of any consequence or value even close to private EMS industry standards, which should be a BIG RED FLAG for Travis County leadership! .  The irony is the privates have HIGHER STANDARDS for public services than either Travis County or the City of Austin.  I am not promoting privatization as the solution, but its worth noting not only for the above reason but because the City’s EMS Union has tried to depict ambulance privatization as a step down when in terms of patient services and cost to the taxpayer for Travis County it would be a step up! 

To fully appreciate how bad the Travis County EMS Inter-local really is, compare it to the following contracting essentials and see for yourself how poorly written the EMS Inter-Local really is. 

Best Practices in Contracting for Emergency Ambulance Service

#1: Hold the EMS service accountable-TC’s EMS Inter-local does not.

Every ambulance service should be evaluated on its ability to deliver results in the areas of clinical excellence, response-time reliability, economic efficiency, bill collection and customer satisfaction. This should be accomplished through performance-based assessment.  A high-performance emergency ambulance service achieves clinical excellence, response-time reliability, economic efficiency, and customer satisfaction—simultaneously. The designated emergency ambulance provider should be required to meet or exceed specified levels of performance in each of these four operational areas. Without accountability, there are no assurances.

• Travis County Inter-local has no stipulations to hold the City of Austin Ambulance Department (EMS) accountable for its performance.  
• There are no meaningful performance outcomes for ambulance response time
• There is no penalty for under performance or incentives for exceptional performance
• There are no monthly data  reporting requirements
• There are no performance requirements for financial controls
• There are no economic efficiencies identified
• There are no clinical benchmarks (other than CPR save rate which represents less than 1% of the work load and is not an indicator of overall effectiveness or clinical competence)
• Bottom line: there are no contractual repercussions for the City of Austin's Ambulance Department for any of their activities, operational, clinical or financial

What are the consequences? 

• At an average 16 minute response time the ability of the ambulance paramedics to make a difference in saving a life is clinically impossible.
• The City ambulance department consistently recommends annual increase in City & County funded ambulances based on a computerized dispatching program that has never been audited for accuracy.  In fact, the City ambulance departments own Medical Director complains that the computer aided dispatching program the City uses to prioritize 9-1-1 medical calls is inherently “flawed and should not be used or relied on for determining future ambulance resource needs”. 
• After the City ambulance department invested millions of dollars in a electronic patient record keeping system, which Travis County had to pay its 30% share, the billing process which was suppose to see huge dollar improvements in its efficiencies, requiring less billing staff remains terribly back logged (45 days) and for the fiscal year 2011 the City approved "adding" billing staff.  So much for cost savings and improved services. 
• Just for fiscal year 2010, STARFlight medical billings, which until recently have been managed under the inter-local by the City ambulance billing section, was discovered to be over $2,500,000 in arrears just for medicare bills!   Any idea how many dollars they are behind in ground ambulance billing?! 
• There is no independent customer satisfaction appraisal process to gauge user satisfaction other than a annual sampling the City does for its various departments, and a less than objective, outdated ambulance department customer service process
• The City ambulance management's only solution for their poor performance is recommendations that Travis County add more  ambulance resources (at over $1,500,000 per unit). For fiscal year 2013, the ambulance director is pushing for Travis County to fund three more ambulances at a cost of almost $5,000,000 and will only improve services by "2%".   An expensive solution given other cheaper and more effective management options including better utilization of existing ambulances using dynamic deployment and peak load staffing, and upgrading County ESD's (fire departments) to paramedic first response (at $150,000 per fire apparatus, considerably cheaper than adding ambulances). 

#2:  Establish an independent oversight entity- TC’s EMS Inter-local does not.

This is a body that has an arm's-length relationship with a provider organization and regularly monitors how it is performing. It periodically requires independent outside audits. To be effective, the independent oversight entity should consist of an unaffiliated and objective group of people selected for their expertise in specific professional disciplines required in the development and oversight of the emergency ambulance service. Community representation on the independent oversight entity should include leaders from areas such as the following:

• Legal

• Accounting

• Business

• Medicine

• Patient advocacy

• Hospital and/or health care

• Local government (elected official)

• Travis County has no "independent" oversight, only a toothless body called the EMS Advisory Panel which meets for one hour, every  month.  It was purposely made impotent by the City to minimize its oversight potential. 
• To effectively manage a "vendor" for emergency ambulance service, be it another government or a private contractor, there MUST be effective oversight including monthly review of actual performance data and regular outside audits of the contract.  
• As noted, this contract has never been independently audited or any consideration given to competitively bidding out service to qualified governmental agencies (example: county fire departments) or private ambulance contractors (example: AMR, Paramedics Plus) over its entire 25 year history.  A fundamental violation in contract best practices. 
• Additionally, the City ambulance management has told County administration their requests for ambulance performance data specific to ESD jurisdictions “yields no benefit” even though this was requested to aid the County and ESD’s in evaluating  how to serve emergency patients more effectively.   In fact the ambulance director stated to a Travis County executive sharing such information with the ESD’s would be “dangerous”.   
• To date, both Travis County and the City Ambulance Departments own Medical Director, have been refused direct access to the agency's computer aided dispatch data on ambulance response and all patient related data from the agency's "paramedic run forms"  for independent performance assessment and medical oversight.  

#3:  Account for all service costs- TC’s EMS Inter-local does not.

An effective emergency ambulance service accounts for all its costs—direct, indirect, and shared.  Cost calculations should include labor, medical communications center, buildings, vehicles, equipment, supplies, liability exposure, administrative overhead, and independent oversight costs.

• In spite of the language in the inter-local allowing only "at cost" expenses, the City of Austin regularly over prices its various direct and indirect services to Travis County. 
• Example:  billing for STARFlight:  earlier in the year the cost for this service was $250,000 but the price "magically" shrunk to under $20,000 when the City became aware Travis County was seeking outside bill collecting services. 
• None of the ambulance cost are itemized with specific correlation between cost for the item and benefit to Travis County residents for the services it receives. 
• None of the new or supplemental costs are required to be OK'd by Travis County's auditor first.
• None of the ambulance service costs are regularly accounted for and certified accurate by an independent audit authority.

#4:  Require system features that ensure economic efficiency- TC’s EMS Inter-local does not.

The volume and location of medical emergencies vary by hour of day and day of week. To reflect this reality, ambulance deployment should be based on geographically deploying the right number of ambulances according to historical call demand and redeploying as events occur. In contrast, “fixed base” or “static” deployment (which is the model the City uses for ambulance deployment), in which shift schedules and unit locations are fixed, is generally discouraged and should not occur other than in remote, low-volume locations.

• The City ambulance operation does not match staffing with demand, resulting in not enough resources during peak demand, and too many during low demand periods. 

• Travis County could use more of its ambulance assets during peak periods and a smaller number for slow periods, supplementing the gaps in service with beefed up ESD first response paramedic engine companies at 1/10th the cost of an ambulance and 40% -60% faster. 
• It could also hold on dispatching a county ambulance resource for the lower priority medical calls until first response confirms a need for patient transport. Rather than fixed deployments, Travis County ambulances should use a combo of fixed and dynamic deployment based on demand levels.  Fixed for slow periods, dynamic for busy periods.    Plus, the two paramedic  supervisors (who drive fully equipped paramedic vehicles), and are paid by Travis County, per the inter-local to oversee county ambulance staff and operations, should be routinely required to stay in the county and actively integrate into ambulance gap coverage when a county ambulance is on a call.     

#5: Ensure long-term high-performance service- TC’s EMS Inter-local does not.

This includes requiring results-oriented performance standards to be met, and then either benchmarking the clinical and financial performance against other recognized high-performance services or engaging in competitive procurement

• Travis County has no such standards.  At the very least the County should bring in a professional EMS contract consultant to establish requirements for ambulance service with clear, concise, measurable performance requirements centered on patient services and cost controls, and cross reference performance between cost of service, quality of care and customer satisfaction (none of which is achieved under the present inter-local agreement).   
  
  

Why does Travis County continue to renew a service agreement that cost more than what other communities pay for comparable EMS service and delivers far less?

The answer:

Travis County, like most municipal and county governments, lacks in-house executive administrative expertise with professional experience and knowledge of EMS best practices, performance contracting and the EMS industry in general. 

What to do?

Solve the one-sided contracting problems and the County regains the critical foot hold needed to responsibly address the future direction of ambulance services and EMS for Travis County.  It does not mean the County has to pull out of a "the present EMS system", it can still be an active participant but under it own terms including how ambulance and first response is delivered in its area of "the system".  But, the County can no longer ignore these contract problems and if it does, only guarantee more of the same: poor service, high operational cost, no say, no control, no standards. 

To Travis County's credit they have taken the first big step and hired an experienced consultant team to evaluate the current EMS level of services.  The results of the consultants report was no surprise, ambulance service is not good in Travis County (that is in terms of operational management, deployment and response, not the quality of the paramedic services once it gets on scene).   Now Travis County must take the next step and hire another professional EMS consultant group with proven EMS contract experience, including writing a real EMS performance contract, developing a master plan for integrating County Fire Department paramedic first response and ambulance operations, and developing a competitive procurement process for county-wide EMS services or more dramatic, a process to cede direct responsibilities for EMS to qualified County ESD fire departments (of the current 13 ESD's, only 6 would fall into this category but they cover the majority of County population).   In the interim, at the very least, the next pending EMS inter-local agreement should be modified as follows:

.   

      1)  The County’s Purchasing and Audit Departments should manage the EMS inter-local with support from the County Emergency Services Executive and the County’s EMS Officer (STARFlight Program Manager).  This joint sharing of oversight provides the critical  financial depth and experience in contract oversight that does not exist in the County’s emergency services section.  This group should also be authorized to use outside legal counsel familiar with performance specific EMS contracting as its counsel and guide for managing the contract and developing new service contracts to be competitively bid for all future service contracts. 

      2)  Either the Auditors Office or preferably an independent accounting firm familiar with this type of service contract should audit the inter-local annually.  Poor performance should be financially penalized as they are in other communities and in turn exceptional performance should be rewarded financially also.


     3)  All inter-local contract cost should be itemized by function (example: PIO services, Special Operations, Tactical Medics, HazMedics, Motorcycle Medics, Communications, Field Supervision, Community Services, Stand-By Services, Training, Office of the Medical Director (by sub-function), Travel, Vehicle Maintenance ) and correlated to the direct services the County receives for these expenses.  An opt out clause should be included for each function to allow the County to select the services it wants for this agreement.  Travis County should no longer be a “minority partner” with a “best effort” agreement with the City of Austin.  Instead, Travis County should pay a single fee for ambulance transport services annually, offset by transport fees. 

   4)  Operational performance measures should reflect a specific national standard for services, NFPA 1710 is probably the best standard since it includes both ambulance and first response.

         5)  Performance reporting, the actual data on EMS response, should be formatted according to the planning and analysis needs of Travis County and its first response agencies and provided on a frequency (example: monthly) beneficial to the County (example: monthly).  Additionally, all Travis County EMS related data (ALL CAD Info) should be automatically dumped into a commercial data warehouse with NO CITY CONTROL or OVERSIGHT.  The data would be managed entirely by Travis County and its contractual Medical Director, and Performance Compliance Administrator.

      6)  Formally recognizing the jurisdictional and lead responsibility of County Fire Departments (ESD’s) for incident command and rescue operations.

      7)  Requiring a City ambulance to be moved into the County to cover for a County ambulance that is sent on City call (a frequent issue and compounded when the county ambulances are prevented from returning to their area of operation after transporting a patient to a local hospital because they keep getting sent on city calls). 

         8)  Requiring the County funded ambulance supervisor units to be used to fill coverage gaps when a County ambulance is on a call (this is not currently done).

      9)  Requiring County first response units to be dispatched simultaneously with the ambulance (there is currently a 2 minute minimum delay)

1    10)  Mandating that the City’s Office of the Medical Director fast track the credentialing program for upgrading County Fire Department units to paramedic/ALS as required by the County  (which he has refused to do because of his claim there are too many paramedics, apparently the only place in the United States with this problem).   Better yet, the County would be ahead of the game both financially and in level of oversight quality if it put out an RFP for County medical direction with detailed expectations, performance requirements, transparency and accountability and selecting the best services from those who submit proposals.

      11)  Create an independent oversight board with authority (teeth) to actively monitor and manage the inter-local.  Include on the board: the auditor, PBO, Emergency Services, ESD Commissioner Representatives, ESD Fire Chief Representatives (I’d recommend ESD 2 and ESD 6), a EMS Contract Administrator (experienced in ambulance contract oversight and statistical analysis), consumers (neighborhood association participation)

 What Can County Taxpayers and Professional Fire-Fighters Do Now?

County taxpayers and professional fire-fighters can tell the Travis County Commissioners what they think by phoning their respective Commissioners, or emailing them or signing a local petition  supporting meaningful change in the current City/County EMS inter-local (go to Change.org to set up such a petition).  Contact information for Travis County can be found by googling "Travis County Commissioners".