Memo outlines Oklahoma City ambulance service alternatives
The Oklahoma City council sees the Emergency Medical Services Authority as a costefficient option for ambulance service, taking an attitude of “if it ain’t broke, don’t fix it.”
The question now is whether EMSA is “broke,” as federal authorities pursue a civil fraud investigation of the ambulance service, its top administrator and a former contractor.
Ward 2 Councilman Ed Shadid, a former EMSA trustee, called for termination of the EMSA trust last month, a day after the federal complaint was filed in Texas.
While the city has alternatives, the complexity of terminating the trust virtually guarantees there will be no change before the next “window of opportunity” — an escape clause that gives the city a onemonth window once every five years to withdraw from the trust.
The latest window was last October, when the city council had a chance to review an array of options presented by the city manager for overseeing and managing the ambulance service.
In the end, the council decidedto stick with EMSA, with only Shadid voting for a change.
Now it will be 2021 before the council has another chance to notify EMSA of its intent to withdraw, and two years after that before the decision would take effect.
The EMSA trust oversees ambulance service in the Tulsa and Oklahoma City metro areas.
EMSA’s role is to contract for services on behalf of the cities. It bills patients and insurance providers, including Medicare and Medicaid. It also buys supplies.
The federal government alleges EMSA and H. Stephen Williamson, its president and chief executive officer, accepted more than $20 million in kickbacks from a contractor, Paramedics Plus LLC.
Paramedics Plus provided paramedics, emergency medical technicians and other personnel between 1998 and 2013. American Medical Response (AMR) is the current ambulance service provider.
Models for taking ambulance service inhouse have included expanding the Fire Department’s already broad role in emergency medical care, and putting the fire chief in charge.
Before the city council voted to remain with EMSA last year, City Manager Jim Couch circulated a memo describing alternatives for providing ambulance service.
Couch described the EMSA system as a “public utility model.”
Alternatives outlined
He said other models break down into five categories: fire department operated, private/for profit, governmentbased, hospital-based, and police-based.
The Fire Department presented two alternatives in 2011, before the last “window of opportunity,” both giving direct control of ambulance operations to the city. They were: •Fire Department oversight of emergency and nonemergency ambulance transport, under supervision of the fire chief. Ambulance transport personnel would be civilian employees of the Fire Department.
•Contracting with a private company for emergency and nonemergency ambulance transport, with oversight and coordination provided through the fire chief’s office. The contractor would be responsible for meeting performance standards.
Couch summarized three additional models for 2016:
•A stand-alone EMS department, managed and staffed by civilian city employees, and reporting to the assistant city manager who oversees police and fire.
•A hybrid system with the Fire Department providing emergency ambulance response and system oversight. A private company would provide backup and nonemergency services.
•Contracting with a private ambulance provider for “basic life support” services and exclusive ambulance transport rights. In this second hybrid model, Fire Department paramedics would be responsible for “advanced life support” and managing emergency scenes.
Advantages seen
Couch said Fire Department and city-managed models offer several advantages.
First, he wrote, ambulances could be positioned at outlying fire stations to help address the longer response times experienced in those areas.
Those “ready ambulances” could be available in cases of extreme and unpredicted surges in call volume.
Staffed by on-duty firefighter paramedics, they also could be placed in service in anticipation of pending disasters, such as tornadoes.
On- and/or off-duty firefighter paramedics in combination with private EMS staff could react quickly to get additional ambulances in service, he said.
Couch noted that “ambulance availability can be insufficient to meet overload demands due to limited staffing.”
Level zero
He was referring to “level zero,” when EMSA reports to the Oklahoma City Fire Department that it has no ambulances available to respond to emergencies.
According to Fire Department records, EMSA went to level zero more than 160 times in 2015. Performance improved in 2016.
When ambulance service goes to level zero, Oklahoma City sends fire rigs to all medical calls.
That defeats efforts to reduce costs and keep fire department paramedics free to respond to the highest-priority calls.
Oklahoma City subsidizes EMSA through EMSAcare, in which residents who opt-in pay $3.65 per month, added to their utility bill.
EMSAcare guarantees that members, in many cases, will incur no outof-pocket expenses for an emergency ambulance call.
EMSA’s current rate for an emergency transport is $1,300 plus mileage.
Budget gap
EMSA says it covers about 80 percent of its operating budget by billing for its services, with the gap covered primarily through EMSAcare.
Next year will be the ninth consecutive year that Oklahoma City has held its EMSAcare rate at $3.65, said Doug Dowler, the city’s budget director.
The Medical Service Program fund — Oklahoma City’s mechanism for paying its share of EMSA operating expenses — is projected to have an ending balance of about $5.4 million by June 30.
However, the fund is expected to run a deficit beginning in fiscal 2019, Dowler said. That would put pressure on the city council to increase the monthly rate.
Terminating the EMSA trust, as called for by Shadid, ultimately would require the governor’s approval, along with the assent of the EMSA trustees and a majority of the Oklahoma City and Tulsa city councils, said Kenneth Jordan, Oklahoma City’s city attorney.
EMSA has an 11member board.
Four spots each are reserved for Tulsa and Oklahoma City, and one each for “nonbeneficiary” suburban jurisdictions in the Tulsa and Oklahoma City areas. EMSA’s medical director also has a board seat.
Terminating the EMSA trust also would require payment of all outstanding EMSA debts from assets, if any, held by EMSA, Jordan said.