Pinellas County Commissioner Ken Welch listens to the proceedings during the Nov. 30 public hearing at the Pinellas Park Performing Arts Center called by the Pinellas County Legislative Delegation to discuss two local bills to change the Special Act that created the EMS Authority. Welch advocated an independent analysis of fire-based transport during a commission work session on Nov. 28.
CLEARWATER – Pilot programs, pension concessions from St. Petersburg, cost-savings on a contract renewal with Paramedics Plus, EMS millage rates by district, fire fees and more.
Pinellas County Commissioners talked about several new ideas to cut costs for Emergency Medical Services during a work session Nov. 28.
Paramedics, firefighters and other interested parties filled the commission chamber to talk about proposed changes to EMS. Should the county continue to contract with a private company, Paramedics Plus, to run Sunstar, or should local fire departments take over ambulance service.
Sunstar employees, many long-time county residents, expressed concern about losing their job. They worry that fire departments won’t hire them because their expertise is with health care – not fighting fires. Paramedics employed at local fire stations also are worried about their jobs due to a second plan that calls for funding fewer positions at municipal fire departments and fire districts.
No one wants to change the current system of providing EMS services that garners praise as one of the best in the nation. It all comes down to affordability in the current economy.
However, commissioners are concerned about the growing dissension as people and organizations take sides.
“There are no bad guys in this scenario,” said Commissioner Ken Welch, who requested the 8 a.m. Monday meeting.
Furthermore, there should be no “us against them” mentality, commissioners conceded. However, difficult decisions are necessary, they say, and not everyone will be happy in the end.
“We’ve received a lot of input,” Welch said of the two plans currently on the table.
The IPS plan, prepared by Integral Performance Solutions, a consultant hired by the county administrator, continues to use Sunstar as the sole provider of ambulance (transport) service and it suggests a new funding formula that would reduce the amount some fire departments would be paid for first responder services.
A second plan, prepared by two local firefighters, has fire departments taking over transport services, emergency and non-emergency, eliminating the contract with Paramedics Plus, the company currently operating as Sunstar under the county’s license.
Welch said the commission had taken “some heat” for not taking a stand in support of either plan; however, he said it was better that commissioners had taken their time to get feedback from the public and others.
Now, the question is “where the board wants to go,” he said.
Welch said he had recently studied the court’s judgment in the county’s 1989 lawsuit against St. Petersburg, in which the city prevailed.
“It was pretty striking,” he said. “If you didn’t read the title, it could have been written for 2011.”
He said it seemed, due to the lawsuit, the county can’t require fire departments to use advanced life support engines instead of rescue units and it can’t use cost averaging to pay for services – two concepts the IPS plan relies on to make EMS more affordable.
“Is IPS implementable,” he asked County Attorney Jim Bennett, who replied that it could be in a “cooperative manner,” but admitted there could be problems with “implementing unilaterally.”
“We’ve listened to everyone, that’s to our credit,” Welch said.
He talked about the problem of managing costs using millage only. He said if the commission managed EMS costs using only increases in millage, the rate most likely have to double to be sufficient.
“We should not do that (raise the millage to the cap) until we make sure the system is as efficient as it can be,” he said.
Welch talked about new options on the table since the commission met with St. Petersburg city officials on Oct. 31. The city of St. Petersburg has offered to take the issue of unfunded pension costs off the table – a savings of $750,000 a year and several million dollars over the next several years.
St. Petersburg also suggested trying a fire-based transport pilot, allowing eight of the city’s rescue units to provide transport services during non-peak hours. The revenue would go to the county, just as the revenue generated by Paramedics Plus goes to the county.
“I’d like to see how much it (the pilot) would save,” he said.
Welch said he would not support any action that was simply managing by millage – or “just transferring the millage line on the TRIM notice (from county to a municipality).”
Lastly, Welch said he would like to see an independent review of losses versus revenues from a fire-based transport system versus continuing the contract with Paramedics Plus.
Bob Swain with the county attorney’s office explained his take the situation from the perspective of the 1989 court judgment in favor of St. Petersburg. He said the county is required to pay for what fire departments and districts use to provide first responder services. He said without a change to the state’s special act that created the countywide EMS Authority, the authority (commission) couldn’t force change, in particular the recommendation by IPS to use ALS engines instead of rescue units.
“It would be hard to put ALS in a community that doesn’t want it,” he said.
Welch talked about a worst-case scenario where a city, for example St. Petersburg, would take the county to court and win.
“That would force the authority to raise the millage,” he said. “And the city could go after general fund dollars.”
Swain said since the special act caps the millage rate, that argument “may or may not be true.” He said the EMS was a separate taxing authority (not acting as the county commission) so there were a lot of unknowns. He said although the amount the authority can raise the millage rate is capped, nothing precluded the commission from allocating more money from other sources to go toward EMS.
Discussion turned to the challenges involved with coordination of 18 different entities providing transport services, including licensing requirements, the need to keep the revenue stream currently provided by Sunstar intact and compliance with Medicare regulations.
“There are definite pros and cons,” Welch said.
Commission Chair Susan Latvala said splitting up the system was a step backwards.
“The system was consolidated by the legislature for a reason,” she said.
She objected to fire-based transport saying the county would have to assume responsibility and risk without having control over the system as it has now.
“I’m disappointed at this point,” she said.
She said all the conversations had done nothing but confirm the county’s responsibility to provide the service but no progress had been made on how to pay for the service.
“We’re left with the only choice to raise millage instead of working with our partners, it’s us against them,” Latvala said. “The (ISP) study shows we can save money with cooperation. But if it doesn’t work, we’ll have to raise the millage. It’s an awkward place to be. I’m disappointed the partners aren’t working with us.”
Commissioner Nancy Bostock said it was important to keep an open mind. She said it was not just a choice between option A and option B. She said it was critical that all the partners be at the table to look at ways to make the system more efficient. She said the key to success was to find a plan that would give everyone something to gain.
Latvala said the county was bearing the expenses.
“We spent money on a study to find efficiencies that is being picked to death by the opposition,” she said. “Now there’s talk about spending more money on another study,” Latvala said. “At some point we have to stop and make a decision and provide the service.”
Commissioner Karen Seel brought up the matter of renewing the Sunstar contract with Paramedics Plus, which expires in October of 2012. County Administrator Bob LaSala said the county was required to tell Paramedics Plus its intentions to renew or not by January.
Paramedics Plus has agreed to waive annual increases based on the Consumer Price Index in exchange for a three-year contract renewal, which would save about $2.5 million a year, or $10 million over four years.
Seel asked about the number of administrative positions in Paramedic Plus’s operation and the continual need to replace the ambulance fleet. Craig Hare, the county’s EMS division manager, said Paramedics Plus’ administrative staff was responsible for a variety of programs, including training, medication management, fleet replacement and patient business services, which make sure ambulance runs are billable, among others.
He said Paramedics Plus also operated a central warehouse for supplies and delivered them to service providers.
Commissioner John Morroni asked Hare about the feasibility of a pilot program. Hare said it would be difficult due to accountability and the design of the current system. He said it was a question of how to run it and implement it.
“We all know paramedics can take patients to the hospital,” he said. “It’s more the mechanics of the process.”
He said considerations would include workload, allocation of resources (equipment) and ensuring response time requirements were met.
And, the biggest sticking point, Paramedics Plus’ contract gives the company rights to be the sole provider of transport service, ensuring a secured revenue stream, which is capped and shared with the county.
Welch said the city of St. Petersburg believes it could save $2.6 million by using eight units to provide transport service during off-peak hours, 8 p.m. to 8 a.m.
Hare said there was a potential problem with safety. He said current standards call for 30 percent workload within a 24-hour period per unit. In other words, in a 24-hour shift, personnel are expected to be engaged in activity 30 percent of that time. Anything over that amount could result in enough downtime to ensure good service. He said there was a risk of crew fatigue.
Bostock said it was important to manage time, but suggested there could be other ways to staff more effectively to save money and would be something the county’s partners could do.
“I’m all for a pilot program,” said Commissioner Neil Brickfield. “But not just for St. Petersburg.”
He suggested an ALS pilot program run by Sunstar in an unincorporated area of the county, such as Seminole.
Mark Postma, COO for Paramedics Plus' Sunstar operation since 2004 and company vice president, said his organization had “sat back and idly watched” the discussions about different plans to overhaul the county’s EMS system.
“We stand on our merits provided to the county,” he said. “We’re (Paramedics Plus) the largest provider of services in Florida.”
The company also provides emergency services to residents of Tulsa and Oklahoma City, Okla., Fort Wayne, Ind., and recently began providing services to Alameda, Calif.
“This is what we do,” he said. “We’re healthcare providers. Ambulance service is health care.”
He talked about unbudgeted costs in the fire-based transport plan proposed by Capt. Jim Millican with Lealman Fire Rescue and Lt. Scott Sanford, firefighter and paramedic with Palm Harbor Rescue. The firefighters’ plan has been gaining support from organizations and municipalities throughout the county, something the IPS plan has yet to accomplish.
Postma said the firefighters did not budget for fuel costs or fleet maintenance and the plan doesn’t account for specialty transport services, such as critical care and mental health. The plan also leaves out a requirement for response time and it has no deployment plan.
He said by contract, Paramedics Plus was monitored throughout the day to ensure it met the response time set by the county and could face fines up to $4 million if it did not perform.
Most deployment plans are secret and proprietary,” Postma said.
“We do that (deployment) very well,” he said.
He estimated it would take twice as many units to go to a fire-based transport system due to logistics involved to keep equipment assets available to respond to fires as well as medical emergencies. He predicted that within a month of fire departments taking over, hospital administrators would be complaining because of the wait time for patient transport.
Over the years, Paramedics Plus has transitioned from providing services from one central location by opening hubs in additional locations. Postma said the change had resulted in savings of $80,000 in fuel costs.
Most commissioners were not in favor of renewing a contract with Paramedics Plus that contains a penalty for violation of the exclusive rights to provide service clause. The proposed contract renewal includes a $5 million penalty. Commissioners say approving a contract with such a clause ties their hands and prevents them from trying pilot programs. LaSala agreed to work with Paramedics Plus to see if that could be changed.
Most of the commission favored offering Paramedics Plus a one-year extension, or perhaps three one-year extensions. Seel favored going with two years. Latvala advocated going with three years because otherwise the company would not be able to offer a reduction in price. She said it had to be able to recoup its capital costs of replacing the fleet.
Scott Sanford, co-author of the firefighters plan, admitted the work “done for free at the kitchen table” might need additional work, “but they are not flaws that can’t be fixed.”
“We put something together on your (commissioners) request,” he said. “You said you wanted to hear ideas. So we gave you ideas.”
He said a lot of emotionally charged opinions were floating around. He also pointed out that 20 percent of Sunstar’s’ (Paramedics Plus) employees were fire department employees. He said if the county went with fire-based transport, many Sunstar employees would probably be hired by fire departments.
He said Paramedics Plus’ claim that fire-based transport would preclude a patient’s ability to go to the hospital of their choice was unfounded.
“The policy is the patient goes where they want to go as long as it is the proper facility,” he said.
Latvala asked who would manage deployment for 18 districts.
“We already deploy people,” Sanford said.
Latvala argued that deployment wasn’t part of the firefighters plan. She said the work the two firefighters had done was “wonderful,” but questioned why they didn’t hire someone if they wanted an independent review to confirm their estimated savings.
“I’ve already spent more money than I intended,” Sanford said.
He said the county had already commissioned a study for $117,000 to find out if the fire department at Palm Harbor could do rescue.
The public and several commissioners advocated getting an independent group involved to review the firefighters plan and the contention that it did not adequately cover costs.
Welch advocates an independent study and trying at least the pilot program suggested by St. Petersburg.
“There are no bad buys,” he said. “There’s nothing wrong with asking for an independent analysis. The numbers on fire-based transport are all over the place.”
Welch said he could not support the IPS recommendations.
Bostock said it was time to take a look at fire-based transport and not necessarily the Millican-Sanford plan. She commented on the many similarities between the firefighters plan and the county’s consultant.
“I want a new plan,” she said.
She suggested it was time to “be bold.”
“We were being bold when we commissioned the (IPS) study,” Latvala said.
Some suggested part of the problem was that the IPS plan was the result of the county’s study and did not involve all the stakeholders. LaSala said a group of city managers and others approved hiring IPS and helped write the scope of the project.
Latvala said she didn’t think it was possible to find agreement between everyone regardless of who did the study or made recommendations. She said the need to find a way to cut costs and pay for the system was the biggest consideration. She said the commission needed to find a plan that was most economical to the county – not necessarily to all.
“It must be most cost effective to the taxpayers, not just for us,” Bostock said.
Seel asked Swain if it would be possible to charge a fire fee. He said a fire fee could not be used to fund EMS. State law requires ad valorem revenue be used to pay for EMS. However, he said fire fees were not uncommon. Pinellas Suncoast Fire and Rescue District charges a fire fee now.
“More jurisdictions are doing that,” he said.
Bennett said a fire fee could be done by ordinance and used to pay for fire services – not EMS.
Swain said a fire fee was something each jurisdiction could do on its own, or if all agreed it could be done countywide.
Seel advocates forming a task force to look at the entire system – fire services and EMS. She is currently on a “listening tour” of the different municipalities to find out the issues that a task force should address.
“Realistically, there is no way we can make holistic changes to the system in less than three years,” she said.
“I don’t understand the purpose of the task force,” Latvala said. “I don’t believe you’ll find consensus with 24 municipalities. It is our responsibility to look at the big picture. We’re just kicking the can down the road.”
LaSala said staff needed direction before the Dec. 6 meeting about continuing negotiations with Paramedics Plus, as well as thoughts on implementing phase 3 of priority dispatch and a new plan that would allow different EMS millage rates to be charged per district.
LaSala cautioned commissioners that taking time for more studies and pilot programs and other measures could mean a delay of three years or more before changes could be made to reduce the cost of the system, meaning commissioners might be left with no choice but to increase the millage rate again in the next couple of years.
He said if nothing is done, by 2013, EMS reserves would be down to 16.3 percent and the system would have a deficit of $4.6 million, based on current projections that property values will continue to fall. He said in 2012, staff estimates reserves will fall to 22.4 percent. Commission policy calls for reserves to remain at 33 percent. LaSala said staff planned to recommend lowering the reserve requirement to 25 percent.
Even if the commission lowers the reserve amount, LaSala said another 20 percent increase in the EMS millage rate would be required for 2013, if no changes were made to the system.
Welch said he wouldn’t support the plan to allow different EMS millage rates instead of one countywide rate.
“It would give us options even if we don’t use it,” Brickfield said.
Latvala said a number of questions come to mind when talking about changes to the EMS system and one of the biggest is the willingness of the municipalities.
“Some cities want to do transport. Others don’t,” she said. “Are we going to split the system up? We’re kicking this can down the road.”
LaSala said staff was trying to give commissioners as many options as they want.
“The issue to protect the level of service is paramount,” he said. “I don’t want the board to feel like it’s boxed in. I don’t want you to be boxed in. We’ll explore with great care and deliberation. … The (EMS) system works very, very well. It’s the cost.”
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