Fire chief’s proposal to have city of Tulsa contract directly with ambulance provider a model used in other communities nationwide

Editor’s Note: The Frontier reported Sunday that the City Council’s vote last week to reject a proposed fee increase for EMSA could spell the beginning of the end of the partnership between the city and the public trust. As part of that story, Fire Chief Ray Driskell outlined his proposal for how the city could take over the ambulance service. Today, we look at how other cities provide emergency medical services.

The Frontier reported Sunday that Tulsa Fire Chief Ray Driskell has a plan for replacing EMSA, should the city ever choose to opt out of its agreement with the public trust.

It’s a simple one: cut out the middleman and have the city contract directly with a private ambulance provider for emergency medical services.

Driskell’s proposed service model is not new. Today we look at two cities doing exactly what the fire chief is suggesting. Those cities are Arlington, Texas, and Colorado Springs, Colo. Each contracts with American Medical Response, the same company EMSA uses to provide emergency medical services in Tulsa.

As part of its agreements with the cities of Arlington and Colorado Springs, AMR provides all of the equipment needed to provide emergency medical services. In each city, the company also carries insurance to cover claims related to its service.

That is the kind of agreement Driskell is proposing, though he acknowledges that he doesn’t know every detail of how such an arrangement would work. He is confident, however, that the transition could be made with no disruption in service and without great expense to the city.

“We don’t change anything. …I just take a deputy chief, put him over there at EMSA,” Driskell said. “The (fire) chief could do the same thing in Oklahoma City, and you keep all of those relationships that you’ve got there.”

When it comes to administrative services, Driskell said he believes the city itself might be able to handle billing, but if not, it could contract out for that service.

EMSA has a staff of 60 people who serve both the Eastern and Western divisions. The employees handle billing, IT, finance, accounting, public relations and operations management.

Under the city’s agreement with EMSA, every five years it has a one-month window in which to opt out of its contract. The next window is October 2021.

Of course, EMSA has its own views on the potential benefits and drawbacks of Driskell’s proposal.

Jan Slater, EMSA Board of Trustees chairwoman, said in an email that EMSA was originally established in 1977 and later expanded because “it’s a cost-effective model for delivering high-quality emergency medical care.”

The authority serves 15 communities in Oklahoma, including Oklahoma City and Tulsa. In EMSA’s Eastern Division, which includes Tulsa, Jenks, Bixby and Sand Springs, AMR employees 330 people. Of those, 276 are registered EMTS or paramedics, according to EMSA.

“As a regional authority representing multiple municipalities and serving more than 1.1 million residents in central and northeastern Oklahoma, there are efficiencies and value in the economy of scale for shared infrastructure and cost,” Slater said. “This model takes the burden of liability, infrastructure and cost of individual cities who are not positioned to be health-care providers in an ever-evolving and complex health-care system.”

What Driskell is not recommending is that the Fire Department take over the city’s ambulance service. That would require hiring personnel and buying equipment the city can’t afford.
EMSA officials last week told city councilors that the authority would retain nearly all of the equipment it uses to serve Tulsa should the city opt out of its agreement. Replacing that equipment would cost approximately $25 million, according to EMSA.

Here’s a brief look at how Arlington, Texas, and Colorado Springs, Colo., operate their EMS programs with AMR as their providers. We also took a look at Broken Arrow, whose Fire Department is also the EMS provider.

ARLINGTON, TEXAS

In Arlington, Texas, home of the Dallas Cowboys, ambulance service has always been provided by a private contractor. Since 2001, the contractor has been AMR.

“The city realized years ago that the private sector is often a more cost-efficient choice for providing some services,” said Arlington Fire Department Assistant Chief David Stapp. “Ambulance service is one of these.”

Under its agreement with the city of Arlington, AMR provides all of the equipment needed to provide EMS service and is required to have insurance to cover claims related to EMS care.

Arlington does not pay a direct fee to AMR for ambulance service. The only money that changes hands is when AMR fails to meet contractually required response times. In those instances, the company pays liquidated damages to the city of Arlington.

For example, if AMR fails to respond to a Priority 1 call within 8 minutes and 59 seconds, liquidated damages are assessed. If the company does not maintain a 90 percent on-time performance each month, liquidated damages are assessed.

Stapp estimates that the city will collect approximately $290,000 in liquidated damages from AMR in fiscal year 2016. Those funds are used to help fund the Fire Department’s Advanced Life Support first-responder program, including the salaries of two full-time medical operations staff.

Arlington’s population is about 388,000, according to the U.S. Census Bureau, and its Fire Department’s annual budget is approximately $46 million. About 320 sworn personnel man the city’s 17 fire stations.

Emergency calls go to the city’s dispatch center, where AMR employees are working next to city dispatch center personnel.

“We go to pretty much all of the calls that the ambulance would go to,” said David Tyler, public information officer for the Arlington Fire Department. “The first person to arrive is in charge of the scene until a higher-ranking person comes in.”

It is AMR’s responsibility to transport the injured person to the hospital, and the company takes care of the billing.

Tyler said AMR is required to offer Arlington residents a voluntary annual subscription program that limits their out-of-pocket expenses for medically necessary ambulance transports. The fee is $67.50 per year.

Each AMR ambulance is staffed with a minimum of one paramedic and one EMT. All sworn Fire Department personnel are certified as either a paramedic or an EMT-Intermediate. Stapp said the split is currently about 50-50.

Fire Department and AMR personnel follow the same emergency medical service rules and are managed by the same medical director.

“We are able to work seamlessly together when we go on calls,” Tyler said.

According to Stapp, Arlington’s per-capita cost for Fire Department services is $125, the lowest of the 11-largest cities in the Metroplex. The median cost per capita is $183. Contracting with a private ambulance provider is one of many methods the city uses to reduce per-capita costs for our citizens.

“Nor do we have any desire to do so,” Stapp said. “Because the contractor providing the service on our behalf, we want direct control of the contract oversight to ensure our expected high standards are delivered to our citizens.”

COLORADO SPRINGS, COLO.

The city of Colorado Springs signed a contract with AMR in 2014 after years of providing ambulance service through an intergovernmental agreement with the El Paso County Emergency Services Agency.

“We changed the relationship by starting our own exclusive agreement with AMR to better provide service to our citizens,” said Jim Webber, the AMR contract administrator for the city.

In Colorado Springs, AMR provides all of the equipment to provide emergency medical services as well as insurance in case of a claim against the EMS provider.

Webber cautioned that seemingly anyone can be named in a tort claim.

“Therefore, it is up to each area to figure out how best to protect themselves,” he said.

Colorado Springs does not pay AMR to provide emergency response services. Instead, AMR, with oversight and assistance from the Colorado Springs Fire Department, provides the service and AMR takes care of the billing.

Each year AMR reimburses the city for the services and materials it contributes to the ambulance service. The payments were approximately $1.1 million a year in fiscal years 2014 and 2015.

The city also receives monthly payments from AMR for liquidated damages, or fees paid by AMR for failure to meet performance requirements.

“In our situation, we don’t own the equipment, nor do we manage the personnel,” Webber said. “We work collaboratively (and) created some benchmarks that we expect to be met by the provider.”

Colorado Springs has a population of 460,000 with 22 fire stations. Approximately 420 sworn firefighters cover a service area spanning a nearly 200-square-mile radius.

Emergency calls are handled by the city’s 911 call center, which dispatches both the Fire Department and AMR.

Colorado Springs does not have a subscriber program, such as Tulsa’s EMSACare, that makes it possible for individuals to pay a monthly fee on their utility bill to cover ambulance service. Instead, individuals are billed directly.

BROKEN ARROW

Broken Arrow, a Tulsa suburb of roughly 106,000, is the largest city in the state to provide its own fire department-based EMS service.

All Broken Arrow firefighters are cross-trained to not only fight fires but to take care of the sick and injured, and that includes transporting them to the hospital.

Broken Arrow has seven fire stations and approximately 173 firefighters. Fire trucks are manned by three firefighters, all of whom have at least basic EMT training.

Fire Chief Jeremy Moore estimates that about half of the city’s firefighters are certified paramedics.

All of the city’s fire stations have an ambulance. Ambulances are manned by an EMT and a paramedic.

Emergency calls are handled by the city’s 911 center. The city contracts with a private company, EMS/MC, to provide billing services.

The BA Fire Department, like most fire departments, spends most of its time responding to medical emergencies. At least 75 to 80 percent of the department’s calls are in response to a medical emergency, Moore said.

Moore could not say exactly how much the city has spent to establish its ambulance service. But he said to do so from scratch would cost at least $2 million. The figure includes $300,000 for a single, high-quality ambulance and other associated costs, including laptop computers, radios and cardiac monitors.

Like Tulsa, Broken Arrow offers a monthly subscription service to cover ambulance costs not covered by an individual’s personal insurance. The fee is $5.45 a month per household for people living within the city limits and $7.50 per month for those outside the city limits but within the Broken Arrow fence line.

The city’s subscription program, called LifeRide, was established in 2015 — the year after the city lost approximately $2.7 million on its ambulance service. That was the third year in a row the city had lost at least $2 million operating its ambulance service.