Andrew Rand is the Executive Director of Advanced Medical Transport of Central Illinois.
How long have you worked in the field of Emergency Medical Services (EMS)?
I received by paramedic license in 1983 and worked in the field for a public provider in Greenville, South Carolina, for several years. After graduating from Clemson University in 1986, I went on to manage a small for-profit ambulance provider in Anderson, South Carolina. During that time we were successful in growing the company substantially by working closely with local governments.
What brought you to Peoria and your current position as executive director for AMTCI?
In the late 1980s in Peoria, each of the three Peoria hospitals operated an ambulance service and there was also a fourth provider called Mobile Medics, which was jointly owned by the hospitals. A joint municipal/hospital task force was formed in 1988 to review the EMS system in search of ways to improve the service. The task force was made up of representatives from the hospitals, city government, police, and fire officials.
The task force commissioned a study from Fitch & Associates, a nationally known consulting firm in EMS. After many months of planning, the task force concluded the best outcome for Peoria would be to merge all four providers into one, and create a high performance, privately owned EMS provider. I was hired in late 1990, and by September 1991, we have successfully restructured the system and created Advanced Medical Transport of Central Illinois.
What changes have you seen over the past five years at AMTCI?
The changes we’ve had have been very positive for the communities we serve as well as the company. We have increased our annual transports from 7,500 in 1991 to over 35,000 in 1995. Our workforce has grown from 20 employees to close to 150. And our fleet of vehicles has grown from four in 1991 to 25 ALS units today. We’ve also added the very best technology available, such as in-field 12-lead EKG’s and Illinois’ first certified critical care ground transportation program.
I am most proud of the employees. I have never seen a group of more dedicated, clinically superior people in the EMS field. Their commitment to excellent patient care is the foundation of AMTCI’s mission statement.
It’s surprising to learn that the Peoria Fire Department was involved in the original creation of AMTCI, since they are now interested in getting into the ambulance business. What’s the current status of the situation you’re facing in Peoria?
First of all, we’ve been aware of the fire department’s interest in ambulance services for several years. It’s just in the last few months that this issue has received public attention. The previous fire chief wanted to enhance the fire department’s first responder capabilities, which I wholeheartedly supported. Since Ernie Russell has become chief, he has sought to placate the fire union through an outright EMS system takeover.
It’s our understanding that the city council has authorized money for a stuffy to determine the viability of the fire department taking over the EMS system. We are presently working to gain a forum with the Peoria City Council, members of the Public Safety Committee, and influential city leaders to make certain that any evaluation includes a hospital and city task force so the playing field can be leveled. We’re also working with members of council to express our strong opposition to any takeover of this extraordinary community asset.
This issue has also resurfaced in Pekin recently. What’s happening there?
This is the second time in 12 months the Pekin Fire Department has attempted to take over EMS services. In spring of 1995, the fire chief’s first proposal was soundly defeated. The ambulance service at that time was provided by a different private company. AMTCI assumed services in Pekin in June, 1995, invested over $700,000 in our startup operation, and doubled the ambulance coverage for the city. Our service has been praised by hospital officials, city personnel, and the citizens we serve.
So we were surprised to learn in December ,1995, that the fire chief’s proposal was back on the table. There are many new faces in Pekin’s city government and I think the fire chief decided to give his proposal another shot. Pekin elected several new city council members and a new mayor in the spring. Also, the city’s first city manager was hired recently. At this time we are aggressively defending out position in the Pekin market through community awareness campaigns.
Why do fire departments want to take over paramedic and ambulance services?
Money. These are tough economic times and local governments are being forced to reduce spending. Today’s firefighters spend less than 15 percent of their time fighting fires. They realize they have to find something to do with their time to justify their staffing levels and budgets. Frankly, they’re scared that the government is ultimately going to have to reduce their size.
It’s really interesting the opinion of most business people is that jobs are incidental to the business of government. What they are really doing in this case is trying to justify their existence by finding more for firefighters to do.
If you look at the way private business operates, you’ll find that when a business has a decline in the demand for a service or product, generally it looks at ways to reduce expenses and payroll to operate more economically. But what the fire department is doing is just the opposite. They want to increase their department’s budget and payroll and create more functions for their under-utilized staff. By responding to 911 emergency medical service (EMS) calls, the fire department hopes to avoid layoffs and budget cuts. What the fire chief doesn’t fully understand is the tremendous financial risk an ambulance service would be to taxpayers.
Does AMTCI have a better solution to the fire department’s budget woes?
Yes. City leaders should carefully assess the data that shows a permanent reduction in the need for fire suppression service and decide how fire departments can be more efficiently managed and maintained. That may include restructuring and/or downsizing city fire departments, or cross-training firefighters as police officers and identifying other public safety jobs they can perform.
What has prompted the fire department’s decision to pursue an EMS takeover at this time?
The fire service has done a good job at eliminating their purpose for existence – structural fires. Through their efforts, legislatively and educationally, the threat of structural fires has declined dramatically. Better building codes, safer materials, and sprinkler systems have all contributed as well. Specifically, during the last 15 years, the incidence of structural fires has been declining at a rate of three to four percent a year. So basically there are very few fires left and an awful lot of firefighters with not much to do.
Would the fire department off superior services at a lower cost?
No. A fire-based EMS system would no be able to offer the same level of patient care more cost effectively. In today’s economic climate, individual cities simply can’t afford to match the financial investment that private companies make in personnel, communications and medical equipment. We cross multiple markets and jurisdictions. Private ambulance providers reap huge savings from economies of scale associated with employee utilization, vehicle purchasing, medical equipment and supplies, and insurance, which are not available to individual cities. Because city fire departments serve a much smaller population than a multi-market private provider, their costs per transport are much higher as well. Also, the salaries, benefits and pensions of fire department personnel are about 50 percent higher than that of the private sector.
What are the disadvantages to the fire department’s plan?
There area several disadvantages to a fire-based paramedic service. The fire chief has no knowledge or experience in paramedic and ambulance operations. His department is not set up to run a for-profit business, which means millions of taxpayer dollars would be at risk. Individual cities do not have the financial resources to buy sophisticated equipment and technology to ensure the finest emergency medical care to area residents. The outcome would be huge deficits, which would have to be subsidized by taxpayers.
When someone calls 911 for a medical emergency today, does the fire department respond free of charge?
No. An individual may not receive a bill for services rendered by the fire department during a 911 call, but fire personnel are paid quite handsomely through your tax dollars. So even if you never use the service, you pay for it. Many firefighters earn more than $51,000 annually working 10 days a month.
What fire chiefs are proposing in their EMS takeover attempts is that they be allowed to double-sip: continue to be subsidized by tax dollars while charging patients a user fee for paramedic service as well.
Why does the fire department sometimes arrive on the scene before AMTCI paramedics?
In Peoria and Tazewell counties the count communication centers control dispatching of units in response to 911 medical emergencies. Because the fire departments are designated first responders, their units are dispatched first. The dispatcher then notifies AMTCI units, which often occurs up to two minutes after the fire department is called.
AMTCI sets self-imposed time criteria for all 911 responses. Currently our average response time in Pekin is under four minutes and we are first on the scene about 50 percent of the time. So even though fire departments are the first responders, the majority of the time we get to the scene first because of our deployment strategies.
How does AMTCI deploy its ambulances?
Our ambulances are constantly on the move. Our crews are not stationed in a fire house; they are sitting on your street corners in their ambulances with a steering wheel in hand. Our ambulances are strategically located throughout the communities. Their placement is determined by analyzing previous emergency response data, which indicates the areas and times of high EMS demand. The response data is entered into AMTCI’s sophisticated Computer-Aided Dispatch (CAD) system, which determines when and where ambulances should be located. This deployment method is called system status management.
When a 911 request comes in, the CAD automatically locates the closest ambulance to respond. If one area is depleted of ambulances, the system will automatically recommend which vehicles should be repositioned to meet demand. This ensures the highest level of service and fastest response times possible around-the-clock.
But since the fire department already responds to some 911 medical calls, they say it is a natural extension of their services to take over the paramedic ambulance service.
I would think that workers trained to spray the wet stuff on the red stuff are not trained to meet the standards of our people who use very skilled procedures to insert tubes in patients’ lungs, needles in their veins, apply electricity to their hearts and administer lifesaving medications and other treatments. This is hardly an extension of putting out a house fire. The medical training of fire personnel is minimal in comparison to an advanced life support system. The services they provide presently include basic CPR, bandaging and minor splinting. In the grand scheme of an acute life-threatening injury or emergency, the firefighter’s role is very brief and limited. The role of our paramedics is very substantial to the total time spent caring for a patient.
How would the fire department work EMS into their current operation?
Fire departments are making an interesting proposition. They say they can provide the service by simply buying a few ambulances and adding a handful of paramedics to their existing firefighter staff. If they are able to add just a few paramedics to get the job done, that means they have an awful lot of firefighters that don’t have anything to do. It makes a whole lot more sense to reduce the size of their organizations than to increase the size of their organizations.
People should be concerned with the duality of the role the fire department would play. Are they firefighters first or are they paramedics first? When they receive simultaneous calls, which call gets answered first? The problem with this type of strategy is that the mission is not distinct. And it’s very difficult to separate the two. We have seen numerous examples of fire-based paramedic services where levels of staffing, as well as the need to suppress fires, jeopardize the mission of patient care in the EMS system. At AMTCI, we are focused on one thing: excellent medical care for the patients we serve.
What other arguments are there against a municipal service?
The obvious argument is that most people agree this is not the time for more government. It is time for much less government. Most communities are seeking opportunities to right-size their organizations and operate with fewer dollars – aggressively pursuing outsourcing as an alternative to adding more government employees.
Privatization and outsourcing are fundamental to government operating more efficiently. To add to the payrolls, pensions and the number of services government provides just ratchets up the long-term costs for the taxpayers
Is it ethical for government to take over a private business simply because the fire department wants to justify its own existence? Can city councils justify displacing a private business that has invested millions and employs 150 residents? Whose business will be the next subject of government takeover? Will police departments go into the private security business? Will libraries begin competing with bookstores?
The few cities that already have experimented with takeovers are finding out what private providers know – making money in EMS is much more complicated than just responding to calls and sending out bills.
So there are cities that currently depend on the fire department for paramedic/ambulance transport services?
Yes. Santa Ana, California, has authorized is fire department to provide ambulance transport. The service costs $2.1 million annually to operate. According to city fire officials, it loses about $1 million every year, which must be subsidized by taxpayers. San Clemente, California, also operates its own ambulance transport service. Local taxpayers subsidize about half its $400,000 annual budget.
Most fire-based programs have a tough time with the numbers when all the facts are on the table. To use some local examples, the city of Moline reported a $583,000 loss for fiscal year 1994-95. That program is very comparable to the size program they are attempting to develop in Pekin. In a January 1995 memo from the City of Moline Finance Department, Moline proposed raising the rates to reduce losses. Even with the increased rates, they are anticipating a $676,000 loss for the current fiscal year.
Published reports regarding Rock Island clearly indicate the city’s struggle with its fire department ambulance program. The city was going to raise rates $150,000 through increase user fees (57 percent) and still was facing a loss of over $125,000.
The city of Des Moines programmed a $1.2 million loss for fiscal year 1995. That’s an awful lot of money to lose. Des Moines, Rock Island and Moline are struggling with their ambulance services and are reportedly looking at ways to privatize them.
Are there cities that currently depend solely on a private provider for paramedic/ambulance transport services?
Absolutely. San Diego, California, privatized its EMS systems nearly 15 years ago. The city’s fire department recently tried to win back the contract in a competitive bidding process, but failed. It is estimated San Diego saves about $2.7 million annually by contracting for EMS with a private provider.
The city of Riverside, California, also contracts for its EMS with a private provider. They city estimates it saves about $1 million annually.
What is the greatest challenge you face in defending your position in the Pekin and Peoria marketplaces?
The issues are very complex. We’re working hard to educate people about such issues as the benefits of privatization, the differences between public safety and health care and the risks of jeopardized patient care.
By far the greatest challenge we have is trying to argue an issue with America’s last great hero – the firefighter. Firefighters have endeared themselves into the hearts of all of us. They risk their lives for public safety every day. One has only to remember the recent Oklahoma City disaster and the heroic efforts of the firefighters. The famous photo of the firefighter carrying the limp body of a small child from the devastated building will forever be etched in many of our minds. Seconds later, however, he handed the injured child to the paramedics from the private ambulance service that exclusively serves Oklahoma City and Tulsa.
The firefighter is one of America’s last great icons and is what many believe a hero should be. In no way do we suggest that their hero status be reduced. The facts, however, no longer support the maintenance of large fire departments that were built in the 1960s when fire was a greater threat/
You mentioned the difference between public safety and health care delivery. Can you elaborate on this point?
The fire department suggests that EMS belongs in the fire service under the realm of public safety. Nothing could be further from the truth. Emergency Medical Services is a conduit through which a patient passes on his or her journey through the healthcare system. We are healthcare providers. We deliver patient care services and in many cases we are the access point to the American health care system.
Emergency medical services and the paramedics that work here at AMTCI are strictly supervised by physicians and under demanding regulations by the Illinois Department of Public Health. We are part of the healthcare team that delivers services from the moment the 911 line rings, all the way up into the hospital surgical units.
Emergency medical services is healthcare. It is not public safety. We are not supervised by local governments, unions or fire chiefs. Instead, we are subordinate to the physicians and the hospitals whose job it is to provide definitive care to the sick and injured. EMS is the front-line of the healthcare system, the gateway to the emergency departments. EMS is not part of public safety. EMS is not a house fire. EMS is joined at the hip with health services delivery.
What is AMTCI’s relationship with the three Peoria hospitals?
AMTCI is owned by Peoria’s three excellent hospitals. We are an integral part of their healthcare delivery systems. AMTCI also enjoys an excellent relationship with Pekin Hospital.
The area hospitals rely on AMTCI for the majority of their transportation needs and they demand the highest level of medical care possible. Peoria is well-respected as a regional healthcare provider with high standards for medical excellence. At AMTCI we strive to mirror that standard of excellence. Through the support of the hospitals, we have become recognized as one of the leading EMS systems in the country.
Doesn’t AMTCI serve a market area much larger than Pekin and Peoria? What would happen to the entire service area if the fire departments are successful in taking over the 911 services?
That’s an important question. AMTCI provides advanced life support ambulance services to over 20 communities in a 700-square-mile area in Peoria and Tazewell counties.
Emergency 911 calls in Pekin and Peoria represent about 50 percent of our total volume. But because of the large scope of our operation and the number of ambulances we have access to at any one time, we’re able to serve a much larger geographic area. If we were to lose the core of our service areas in Peoria and Pekin, the entire system would collapse. The system would be fragmented and smaller towns such as Dunlap, Farmington, North Pekin and Bartonville would be without paramedic services. IT is highly unlikely Peoria’s Fire Department would be willing or able to respond to the EMS needs of the rural and unincorporated areas.
In addition, we transport over 15,000 non-emergency patients each year. Dialysis patients, skilled nursing home residents and many others require ambulance transportation on a non-emergency basis. These people would be left without ambulance services.
AMTCI also has developed Illinois’ first certified critical care ground transportation program, which is used to transport intensive care patients from outlying hospitals to the medical centers in Peoria. This is a unique program that requires specially trained paramedics and utilizes a one-of-a-kind vehicle which is really an intensive care unit on wheels. Peoria would lose this service as well. The real losers in all of this would be the patients. And the taxpayers.
With all the changes in healthcare, isn’t this a risky time to be entering the field?
I can’t think of a worse time to roll the dice on a new healthcare venture. Not only are our present reimbursement dollars being reduced each year – particularly those from Medicare and Medicaid, which make up 70 percent of our transports – but we are not beginning to feel the squeeze from the private sector, insurance companies, managed care, and capitation. The reimbursement changes that are coming are frightening and will shape many additional changes over the next few years.
The role of the paramedic is changing as well. Currently, we respond to a call, treat the patient, and transport to the hospital. As new frontiers in EMS develop, the way we do business will change. The EMS service of the futures will more than likely include treatment at the scene and a reduction in the number of patients that are transported. With managed care and capitation, hospitals are seeing fewer admissions which means less transports. EMS will probably be linked more strongly with home health and be staffed by a higher-trained paramedic, nurse or physician’s assistant that can treat patients in their homes and release them to home care. Reimbursement for this type of service is unclear and will probably be linked into regional healthcare networks.
What about liability issues of providing EMS services?
The liability issues in EMS are extraordinary. Workplace safety issues, motor vehicle accidents, and medial malpractice are the three biggest areas of concern. With a private company such as AMTCI, the city and its taxpayers are not at risk. With a city-run program, the taxpayers are the ones that ultimately pay for any liability issues that arise. In fact, a fire-based system in Bloomington settled a seven-figure claim for negligence in an accident a few years ago.
Does AMTCI respond to an emergency call is a patient is poor or doesn’t have insurance?
Absolutely. AMTCI responds to all 911 emergency medical calls regardless of the patient’s ability to pay and provides the best possible medical treatment available. After the services are rendered, AMTCI bills patients’ insurance companies, Medicare or Medicaid. If patients don’t have insurance, but have the means to pay, the company bills them directly. If patients have no insurance or means to pay, AMTCI writes off the bill as uncompensated care.
In 1995, AMTCI provided nearly $400,000 in charitable ambulance services to those who could not afford the cost of medical care. We provided the cities we serve with an additional $187,000 in community services, such as event standbys and free educational programs. AMTCI also wrote off an additional half-a-million dollars in bad debt.
We provided $4.3 million in discounts to Medicare and Public Aid recipients in 1995.
One of the greatest fallacies the fire department has is their perceived ability to generate revenue. They use a very different crystal ball than I do. In fact, our accounting system is well-aged and very predictable in terms of net receipts. We presently average collecting about 48 cents on the dollar. This is because of deep discounts for Medicare/Medicaid and the tremendous amount of uncompensated care or bad debt.
Fire departments think you throw a stamp on a bill and it gets paid. It’s just not that easy.
What is the average charge when AMTCI responds to a 911 call?
All AMTCI ambulances are hospital emergency rooms on wheels. They are staffed with certified paramedics trained in advanced life support, and emergency medical technicians-intermediates trained in life support.
The average base rate for an emergency medical service call is $400. There are additional charges for certain medical supplies and equipment usage, and mileage.
Are you concerned about the influence the firefighters’ union may have over the city councils in Pekin and Peoria?
No, I think the firefighters believe they have more clout and influence over the councils than they really do. Just because they make campaign contributions, staff campaigns, phone call, and go door-to-door doesn’t mean citizens are unaware of the facts. I think most people will realize what this issue is all about. The firefighters are trying to justify their job existence.
I believe over the long term, this issue will be clearly evaluated and the councils will make the right decision to leave EMS in the capable hands of the private sector.
We are skilled paramedics and medical technicians trained to save lives. Firefighters should spend their time doing what they do best – putting out fires – and allow AMTCI to do what it does best – saving lives. IBI