HomeMy WebLinkAboutMinutes Ambulance Advisory Committee - 04/19/1990AMBULANCE ADVISORY COMMITTEE,
MINUTES
April...19:, 199 0
7:30 a.m., MMC Basement
Members Present
Pauline Clarke, Chairperson
Virginia Brown, Vice- Chair.
Carl Young
Ezequiel P. Elizondo
Dr. David Gray
Wheeler Lipes
Dr. James Geddes
Mrs. Pauline Clarke, Chairperson,
asked the Committee if they woul d
presentation before the regular
agreed.
g 0 _2-y
Others Present:
Dr. Richard Davis
Juan J. Adame
Ronald Coleman
Fela Leal
Kevin Sigler
called the meeting to order. She
like to listen to Jack Stout's
order of business to which they
Mr. Stout stated that since most members had heard his presentation
at the court house the day before it would be better if he would
response to any questions the committee may have.
Mr. Coleman began the discussion by stating that according to the
EMS billing office only forty percent of the people that we ser<re
have insurance. Of that forty percent, Medicare makes up ten
percent, Medicaid five percent, and other types of insurance
twenty -five percent. Last year that forty percent paid the over all
thirty -three percent collection rate.
Because of the new fee schedule the collection rate for the year
may be up to forty--five percent.
Mr. Lipes asked what was Medicare paying, to which Mr. Coleman
responded that they were paying one hundred fifty -two dollars out
of three hundred fourteen dollars. The department is stuck at the
current fee schedule for reimbursement.
Mr. Stout stated that one way to get out of the existing
reimbursement schedule is to change providers. This would allow the
service to bill up to the prevailing rates after six months. What's
limiting the service in Corpus Christi is its previous lower
charges and the federal policies that only allow increases with
basically an inflation index charge policy. Texas also has low
prevailing rates.
Mr. Stout further added that the American Ambulance Association as
of about three weeks ago has opened the door with the federal
government to completely reform how ambulance services are
reimbursed. We really shouldn't be reimbursed by a prevailing rate
structure.
Discussion followed.
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Mr. Stout stated that assuming that the Corpus Christi area has a
fifty fifty mixture of emergency and non - emergency runs, you will
find out that the non - emergency market is much more dominated by
Medicare eligible people and many of those have company insurance
on top of that. Remembering that the non- emergency fee rate is
lower, the collection rate would probably be between sixty and
sixty -five percent.
Most services charge higher than Medicare's allowed charge and
don't accept assignment on people that are fairly well to do. When
patients are billed they are held accountable for the entire bill.
Medicare will reimburse them for part, a third of the bill. On
people that are less well to do we'll accept assignment. We absorb
what's called the contractual allowance and by law we're required
to bill them for twenty percent of the allowed charge which is
typically a thirty or forty dollar figure.
If you do the above real well I believe that you might be able to
do forty -six, maybe forty -eight as we do in Fort Worth. So if
that's true, then there are no financial objections that can hold
up against *chat I've been saying.
I'm assuming a forty -five percent collection rate over all. Throw
in five dollars per capita per year subsidy, add in the revenues
from eight thousand or nine thousand new non - emergency transports.
And you can see there's plenty of money to run the service.
Ms. Clarke asked if Mr. Stout could get into some of the nitty-
gritty of how the service would operate.
Discussion followed.
Mr. Stout stated that there is like a hundred and fifth or two
hundred things you have to actually do, but none of them work if
you don't change from the twenty -four hour shifts. He then
proceeded to draw a graph depicting the possible demand patterns
during a regular twenty -four hour period. He determined that during
the peak time for about a three or four hour period nine ambulance
units would be needed to serve Corpus Christi. During the remaining
time periods a considerable less number of crews would be needed.
Since it cost approximately sixty dollars an hour on the average
to run a crew it would be impossible to run all nine crews one
hundred percent of the time.
Mr. Stout continued stating that when staff first look at the
demand patterns they tend to develop a schedule which includes a
mixture of twenty -four hour crews in combination with twelve and
eight hour crews. The problem with this is that when you get down
to where your nighttime coverage is about what it should be, the
twenty -four hour crew runs too much and may not get enough rest and
sleep. You don't want to be that person's patient' because their
Page 3
judgment is not clear. Physicians in Kansas City looked at this and
outlawed twenty --four hour crews, saying there are just too many
chances for very tired people to make bad judgments that are
dangerous to patients and themselves as drivers. You could get a
ninety percent response time under eight minutes working if you
geographically employed crews correctly.
Dr. Gray asked if this were possible in a city as long and skinny
as Corpus Christi.
Mr. Stout replied that this was possible in Corpus Christi. When
you've got nine crews on in the peaks and they're rolling, you've
got the area covered. At nighttime, three o'clock in the morning'
there's no traffic at all and you've got good thoroughfares.
Dr. Gray asked. if Mr. Stout had developed a system for medical
oversight and also for trained paramedics to be the first person
to talk to somebody on the phone (911), to which Mr. Stout
responded yes.
Dr. Gray asked Mr. Stout about a question Ron Coleman had asked the
night before regarding the Fort Worth system which kind of gave the
implication that it might be a run away system if the contractor
decided they needed more profit.
Mr. Stout stated that contractors don't control billings,
collections or accounts receivable management, nor do they control
rates. The ambulance authority, which is a governmental entity,
like an airport authority, is in charge of all the billings,
collections and accounts receivable management.
When they go out for bids they usually don't seek the lowest bid,
rather they establish a minimum standard of care. They inform the
bidder that there is five dollars per capita per year plus expected
revenues collected from fees for service and a subscription
program.
Mr. Stout proceeded to draw a chart depicting a possible
organizational structure with individual areas of responsibility.
The ambulance authority furnishes the building, the main facility,
the maintenance facility for all the vehicles and so forth. it
furnishes the communication system, the communication center. The
authority usually owns the dispatching computers and all the
infrastructure. Basically they own --all the items who's
amortization exceeds the life of the contractor's contract.
If the contractor goes bankrupt, or you fire him, you don't want
him taking all that equipment away from you or you don't want him
offering it to you for triple what he paid for it. You don't want
to be that dependent on the contractor.
Mr. Stout added that there had been two instances in the industry
where fire departments bidded in and participated in the bidding.
Page 4
Mr. Stout continued stating that expected revenues are divided
between infrastructure, contractor staffing and accounts receivable
management.
During the bidding process the first thing you do is qualify the.
bidders. You are not interested in what a company has to offer if
that company has no qualifications to do the work. You entertain
bids from firms who have a track record of having been able to meet
the clinical and response time standards in communities of
approximately Corpus Christi's size or larger and have done so at
a profit.
We then divide the projected revenue by twelve and come up with the
monthly payments to the contractor, minus ten dollars a minute for
every late run, plus additional monies from long distance
transfers, special events coverage and other work done by the
contractor. We allow the monthly payment to increase at eighty
percent of the "inflation of the CPI". So the contractor has to
outperform the whole rest of the economy just a bit. The average
firm in the economy is at a hundred percent of the CPI.
A five year contract is awarded to the company that will promise
the highest standard of care. During the bid process minimum
standards are outlined such as certified medics and a response time
of sixty percent. Wage rates are.also stipulated.
The contractor will not earn any more than what we have stated plus
some inflators such as fuel prices and insurance rates. He should
also be required to put up a performance bond between five- hundred
thousand and one million dollars. The liquid damages clause should
state that if the contractor doesn't do the job right, he loses the
million dollars. This will prevent cavalier bidding. That's why in
thirteen years we've never had a contractor fail yet in cities
where we have done this.
Mr. Elizondo asked Mr. S- bout— to - -ep a n - - "uli utilization".
Mr. Stout stated that "unit hour utilization ratio" is the term
used by the industry to measure performance other than response
times. To arrive at this you divide the average number of runs per
week by the total unit hours per week
Using Corpus Christi data Mr. Stout outlined the following:
8,375 Number of calls per year
52 Number of weeks in a year
153.8 Utilization (average number of runs per week)
24 Number of hours in a day
x 7 Number of days in a week
1,176 Total hours in a week
153.8 divided by 1,176 = .13 Unit Hour Utilization Ratio.
Page 5
A ".13 unit hour utilization ratio" means a paramedic in our own
system transports an average of .13 patients per hour on duty. You
could turn this around and say that a paramedic is 7.69 hours on
duty per patient transport. That's why, according to Mr. Stout,
the Corpus Christi system is inefficient.
Discussion followed.
Mr. Elizondo asked if Mr. Stout could provide some input in
Pinellas County's request for qualifications regarding seventy
million dollars worth of improvements. There was a reference in the
report that the cities and counties that chose to participate in
this effort had to make seventy million dollars worth of
improvements to their system.
Mr. Stout responded that this
EMS authority about eight year
point five million tax for EMS.
million dollars a year, goes
first responder programs. A
expect, wasted.
was not true. The state created an
s ago and allowed them to have a one
All of that money, which is thirty
to fire departments to fund their
great deal of it is, as you might
Discussion followed.
Mr. Elizondo asked if it were possible to find in the market a
qualified ambulance service provider that met the criteria that was
laid out on the formula for success with a subsidy some where in
the range of five dollars?
Mr. Stout stated this could be done. With a five dollar subsidy and
the standards discussed, Corpus Christi would be an extremely
desirable market. The reason for this is the nice area and the
higher paramedic wage scale which would be maintained.
Discussion followed regarding possible strategies which would
assure that no current paramedics would loose their jobs during a
transition period.
Mr. Elizondo asked what would be the added cost of the additional
first response runs as a result of a single provider ambulance
system.
Mr. Stout stated there would be no additional manpower cost. There
would however be some additional cost such --as training, equipment,
expendables and supplies, fuel, accelerated maintenance,
accelerated depreciation and a couple of other items. According to
Mr. Stout, the experts in the industry have determined that the
additional cost would come to twenty -seven dollars per transport.
using Clawson's protocol the present twenty -five hundred first
responses being conducted by the fire department would increase by
fifteen hundred. So the increase cost could be determined by
multiplying fifteen hundred by twenty -seven dollars.
Discussion followed.
Page 6
Mr. Stout continued, stating that in establishing the bid process
you must determine what the minimum criteria will be. Potential
bidders won't bid unless an allocated point system has been
established and those reviewing the bids understand HMS. Bidders
also object to fire departments and city councils reviewing bids
because they feel they will not be objective and take the time
necessary to review the bids thoroughly.
Mr. Stout emphasized that a five dollar per capita would be plenty
of money to get our system working right. There are also plenty of
existing models to choose from.
Discussion followed.
I. Approval of the January 18,1990, Minutes - Pauline Clarke:
Motion was made by Mr. Lipes, seconded by Mrs. Brown to approve the
minutes. Motion passed. t
II. Financial Report - David Moore:
Mr. Sigler presented the Financial Report for Mr. Moore who was
absent. He stated that collections for the first quarter of this
year as opposed to last year are up approximately eight -two
percent, which is due to the new fee increases. Collections are
consistently at around the sixty thousand dollar mark.
The main concern continues to be the Medicare and Medicaid
programs. As we have mentioned, they're paying about one -half of
what our fee is for Advanced Life Support and about one fourth of
the fee for Basic Life Support. We've got some new forms that
Medicaid has allowed us to use that will hopefully reduce some of
the frequent travelers on the EMS system. The form will state that
the patient can be held responsible for the bill if Medicaid denies
payment. This is totally unusual since I was trained that we
always had to accept Medicaid, and not look to the patient. If
Medicaid denies some of these transports, we can look to the
patient for payment.
Mr. Coleman stated that Medicaid does not pay for anyone actively
seizuring or in labor since it does not consider this an emergency.
Dr. Davis commented that the only advantage to the new form will
be that if frequent users get billed for a-period of time they may
opt to go by some other mechanism. You don't really expect any
revenue to come in.
Mr. Sigler added that the same problem exists with Medicare.
Discussion followed.
Mr. Lipes stated that Medicaid and Medicare had to put the lid on
because in '79 we had one family who made twenty or thirty calls.
Page 7
Dr. Gray replied that he would rather see the problem corrected by
some public education rather than allowing the most ignorant level
of the system to decide whether they need transportation or not.
Discussion followed.
Ms. Clarke asked if privatization would correct the problem.
Discussion followed.
Dr. Gray stated that the private contractor would be free to be
innovative. They would also have someone with medical training
making the decisions as to whether to transport. If they decided
that a person is misusing the ambulance they could use some other
means to transport.
Discussion followed.
Mrs. Clark stated that she had yet to see where the money would
come from.
Dr. Gray replied that it's the old capitalist profit motive theory
and that the money would continue to come from where its coming
now. Where you're gaining on the current system is that you're
making yourself more efficient. The new system would cost about
half the present system. Where we're losing right now, is in giving
away all the paying business to private contractors and we don't
have to.
Mr. Young asked Mr. Sigler if there were records of all ambulance
emergency calls by track and if so could we come up with more
efficient time schedules. Mr. Young also asked if a report by the
types of runs such as car wrecks, diabetics, fractures and burns
could be generated.
Mr. Sigler responded yes to both questions.
Mr. Young added that for training purposes it's good to know where
you want to put major emphasis.
III. Election of officers - Mrs. Clarke
Mrs. Clarke opened the floor for nominations of Chairman.
Motion was made by Mr. Lipes, and seconded by Mrs. Brown to
nominate Mrs. Clarke for Chairman.
Discussion followed regarding the fact that Mrs. Clarke's term will
expire on July 31, 1990. It was decided that the issue would be
settled later.
Mrs. Clarke was reelected by acclamation.
Page 8
Mrs. Clarke opened the floor for nominations of Vice- Chairman.
Mrs. Brown nominated Mr. Young for Vice- Chairman. Mr. Young
declined and Ms. Brown withdrew her nomination.
Mrs. Clarke yielded the Chair to Mrs. Brown and nominated Ms. Brown
for Vice- Chairman. Nomination was seconded by Mr. Lipes.
Mrs. Brown was unanimously elected Vice - Chairman.
TV. EMS Director's Report - Ronald Coleman
Mr. Coleman refereed the committee to the cardiac arrest study
provided in the packet. A comparison of 1988 with 1989, indicates
a decrease in the number of cardiac arrest patients. Within this
group there also was a decrease in the number of patients who were
in ventricular fibrillation from eighty in 1988 to sixty -six in
1989, if you omit the V tack patients. What this means is we have
a public education need for people to know when to dial 911.
Whats happening is people are delaying the call into 911 by first
looking for other means of assistance. By the time the engine
company arrives its to late.
Approximately thirty -three percent of the patients that the fire
department finds in cardiac arrest are in Asystole (straight line).
Another thirty -three percent are in Ventricular Fibrillation.
Only one person in five has or has had CPR performed on them before
the fire department arrived on scene. We have a problem with the
community wide CPR program. Our goal should be to have one third
of our citizens trained in CPR, approximately one hundred thousand.
When this goal has been achieved, in conjunction with the automatic
defibrillators carried on the engine companies , then we should see
the percentage of people surviving cardiac arrest increase.
Mr. Coleman continued, stating that a program is needed to teach
the public the value of administering CPR before the engine company
arrives. One alternative could be to educate high school students
and requiring the attainment of a CPR card or first aid card before
completing high school. This is now being done in some schools in
Florida.
Mr. Young suggested that possibly members of the medical society
could play a vital role in this, especially by approaching the
school system. Currently the fire department conducts two CPR
classes a month. In addition to CPR, the classes teach early
warning signs, how to properly call for help, risk factors and how
to lead a healthier life. But if we can't get assistance from the
right people, we're never going to get this done.
Page 9
Mr. Coleman stated that 1990 should be a good year since all the
defibrillators have now been deployed. Mr. Stout reported
yesterday that we had a sixty percent reliability, responding
within eight minutes. However our tracking records indicate that
since January we've been reaching over eighty percent of the people
within eight minutes. This is a twenty percent improvement.
We have also been tracking how many ambulance units are on call at
the same time. During the month of March only on eight separate
occasions were all seven units out on calls. So at this time seven
ambulances appear to be handling the situation. It would be up to
the board to recommend to whoever some of the advantages of having
the stagnant number.
Mr. Young informed the committee of an incident he witnessed where
an engine company who had arrived at a scene failed to use the
defibrillator. He would like assurances that there is a standard
operating procedure and it is being followed. He would like to make
certain that our citizens are getting the CPR and the use of the
equipment by the first responder, which is the engine company.
There were five hundred and ninety -six deaths from heart disease
and about three hundred and one of those were from ischemic heart
disease of the type the would bring on an arrhythmia that would
need the defibrillator.
Mr. Coleman assured Mr. Young that procedures are being followed
and checked on for compliance. The SOP has been issued signed by
the medical director and Fire Chief.
Mr. Young added that he beliefs that failure to do this kind of
thing, when it is indicated and when you have the equipment and
trained man, could get the city in a lot of legal trouble.
Dr. Davis, commenting on Mr. Coleman's cardiac arrest report,
stating that not all of those people fell down in those rhythms.
Ninety percent of them fell down in ventricular fibrillation and
then because of time delay deteriorated to those rhythms. Had the
patients called more readily, and had the turn around time been
faster, we might have gotten the electricity to them while they
were still in ventricular fibrillation and that might have been
able to make a difference.
Dr. Gray asked if it would be feasible tomorrow to place paramedics
in the 911 system and have them on the -other end of the phone
within ten seconds of a call?
Discussion followed.
Mr. Elizondo suggested the fire department explore the issue and
report back at the next meeting. Maybe a cooperative effort between
fire department and the police department could be worked out.
Page 10
Dr. Davis suggested the issue be facilitated at Mr. Elizondo's
level. This issue has been brought to the police department's
attention for ten years and for ten years the answer has been that
a new computer is going to be purchased which will solve all our
problems. Computers will not solve the training issues. The police
department has not really been open to outside suggestions.
Mrs. Clarke requested that she would like the fire department and
Mr. Elizondo's office to proceed with developing the concept and
the framework as far as to what it would take to develop paramedic
capability at the dispatch center to respond to the EMS calls. Is
the new equipment at the new building going to provide for this?
Mr. Lipes stated that in the interest of life safety for citizens
of this community, he would make the motion that the committee
request an investigation by the fire department as to the
possibility of a paramedic being in the 911 system, and that this
be done not later than June 1, 1990.
Dr. Gray Second.
Discussion on the motion followed.
Mrs. Brown stated that any evaluation /screening that can be made
during 911 is going to save lives and save nuisance calls.
Motion passed unanimously.
Mr. Lilpes stated that another motion was needed to specifically
address the education and training of the existing people. We now
need to upgrade those people who are there who haven't had any
training in a couple of years.
Mr. Young made the motion that during the interval time while we
wait to see what happens with the paramedics assisting the dispatch
office, we utilize the fire department EMS training officers in
giving the staff of the dispatching service some basic information
on emergency services so they can more intelligently answer the
citizens that call in.
Motion was seconded by Mr. Elizondo.
Discussion on the motion followed.
Dr. Gray voiced concern that the committee was going to try to do
something with personnel that aren't capable of doing it, who have
no medical background. We need a paramedic who's been in the field,
who's looked at patients.
Mr. Young responded by says that while we're waiting to see what
can be worked out, every day goes by that calls aren't screened.
Page 11
Mr. Lipes stated that current dispatchers met some standard to get
into the job description they're filling. Those standards were
approved along the lines before they put 911 in. If those
standards are not adequate or if they aren't on that minimum, then
we've got to get from where they are to here, and if they need
refreshers, then we ought to utilize the people we have to give
them refreshers.
Further discussion on the motion followed.
The motion passed unanimously.
Mr. Coleman continued with his report referring the committee to
the budget request for 1990 - 91, which was provided in their
packet. The budget request is two hundred thousand more than the
current budget. This is due to the increase cost of insurance and
administrative costs to city administration which are beyond
anyone's control. These costs are computed by the risk management
office for insurance coverage and city administration for indirect
costs such as legal services, purchasing,etc.
Mr. Lipes asked what the ten thousand dollars in "reserve
appropriation" intended to cover?
Mr. Coleman stated this was budgeted for cost overruns. Last year
it was used to cover the overrun in vehicle maintenance. Even
though we had to move ten thousand dollars to cover vehicle
maintenance, we spent almost half the cost of what it was costing
when maintenance was being performed at the city service center.
Mr. Coleman added that there's been a dramatic decrease in downtime
because of the excellent preventive maintenance being preformed by
the fire department's own service shop personnel.
We will also see a decrease in overall maintenance cost due to the
new design we have gone to on our ambulances. This new design has
a generator on the outside of the ambulance to run the modules'
equipment separate from the chassis.
Dr. Davis commented that he had asked Mr. Coleman to split out some
of the maintenance line items by true maintenance cost and those
cost associated with repairing vehicles which had been in a wreck.
We're having a lot more saving in true vehicle maintenance than is
apparent in some of the budget figures.
Mr. Lipes asked if ambulance drivers had fuel credit cards for
emergencies.
Mr. Coleman replied that ambulances fill up at city stations. It
costs fifty cents per mile to operate a city ambulance.
Mr. Elizondo stated that with all the E.P.A. guidelines he hoped
Page 12
the city would get out of the fuel business and eventually have
credit cards.
Dr. Gray asked Mr. Coleman if paramedics are currently being
trained and certified to do a pleural or a pericardial
decompression in the field?
Mr. Coleman replied that a training curriculum has already been
developed and will be implemented when it is approved.
Discussion followed.
Mr. Elizondo asked if the commitment to replace old ambulances is
continuing.
Mr. Coleman replied that a brand new ambulance arrived last week
and will be on the road next week. It will go to station fourteen
and replace the reserve ambulance which is being used as the
seventh ambulance.
A remount, which involves taking an old chassis out and replacing
it with a new one and using the old existing box, will be completed
this budget year. This will essentially give us a new unit at half
the price. The proposed budget has a new ambulance and a remount
budgeted for next year.
V. Discussion of Ambulance Advisory Committee Membership -- Pauline
Clarke
Mrs. Clarke began the discussion by stating that because the
hospital district has withdrawn from the partnership, the committee
will have a new makeup. Mrs. Brown asked who is going to determine
this.
Mr. Elizondo replied that the city would determine the new makeup.
He further added that he was not sure that the host agencies are
as important as the makeup of the committee. He may however see a
need for expansion from the perspective of where we need to go.
There are a lot of issues before the committee and we are going to
need help from the medical community and the professionals that
are in the business.
To this date the county has not said they are going to contribute
as of August 1st. They are reserving some dollars and basically
saying they are interested in an emergency medical service and
think they would like to participate. They would like for us to
take a serious look at how we do business.
Mr. Elizondo added that the council could very well say they will
provide the money, and be satisfied with letting the hospital
district continue making appointments to the committee. So there
may or may not be a change.
Dr. Davis stated there was no time urgency in doing this.
Page 13
Discussion followed.
Mr. Elizondo commented that a recommendation will go to the city
council stating that for the time being the Ambulance Advisory
Committee needs to continue as is or until the county decides what
it is going to do.
Dr. Gray asked if it would be appropriate if the committee itself
recommend to the city council what to do with the Ambulance
Advisory Committee.
Discussion followed.
Mr. Lippes stated that it wasn't up to the Ambulance Advisory
Committee to tell the city council how the committee should be
structured.
Mrs. Clarke pointed out that some time back Mary Rhodes from the
city council was assigned to look at committees and commissions
and re- evaluate their mission and functions. At that time it was
recommended that this committee needed to be looked at. The
committee was first set up in 1973 and obviously there's been
changes in everything. This was said over a year ago.
Mr. Elizondo stated that if Dr. Gray's question is whether we
should advice the city council to continue the committee because
the purpose of the committee is going to continue to exist
regardless of who provides funding, the answer is yes. However,
he is not prepared, on behalf of the committee, to instruct the
council on who to appoint.
Mrs Brown requested that copies of Mr. Stout's report be provided
to all committee members.
VI. Unfinished Business
None
VII. New Business
The next scheduled meeting will be on June 14, 1990, at MMC.
Meeting adjourned at 9:30 a.m.
Page 14
Respectfully submitted,
Ricardo R. Ramos
Administrative Assistant V
Approved:
Pauline Clarke
Chairperson
Date: