CAMDEN — Key advice has been handed to a group of town leaders tasked with reviewing competing emergency medical service proposals: Figure out how EMS can serve communities in other ways besides strictly responding to crises. Can they blend the growing practice of community paramedicine and work with hospitals and nursing homes to keep EMS ready for accidents and cardiac arrests, while staying financially afloat?
It's a new world for EMS providers, who, like hospitals and doctors, are adjusting to shrinking revenue streams. And the EMS business is not that financially lucrative, unless a region's population is large enough, or wealthy enough, to sustain it. This has hit home hard for Camden, Hope, Lincolnville and Rockport, which are currently sorting through a mass of detailed proposals and ideas about the future of EMS in their communities.
The process comes at a time when health care is going through massive disruption to ways of doing business. Hospitals, physicians, nursing homes, and now ambulance services are being forced to adjust budgets as they also adhere to multiple permitting and licensing layers, and at times, regulations that seem to make little sense.
Delta Ambulance service proposes covering the four towns with a $44 per capita fee that totals $552,640. Breaking down town by town: Camden, $231,396; Hope, $62,832; Lincolnville, $103,400; and Rockport, $155,012.
Camden First Aid Association is asking the towns to contribute 37 percent of its total $407,000 budget: $174,000 from Camden, $129,000 from Rockport, $77,000 from Lincolnville and $27,000 from Hope.
Northeast Mobile Health Services proposes, for the first two years of a contract, charging Camden $10,000; Hope, $1,000; Lincolnville, $5,000; and Rockport, $12,000.
Sterling Emergency Medical Services proposes charging Hope $6,500 annually for two years.
“Nobody is getting rich,” said Rick Petrie, who has been a paramedic for 31 years, and has topped out in pay at $23 an hour. "Except in Texas, where they didn't have ambulances but were actually billing for services [a $450 million Medicare fraud case that included four ambulance providers].
Petrie is also executive director of Atlantic Partners EMS, a Winslow-based nonprofit whose mission is to enhance EMS and public safety through training, collaboration and cooperation among providers. Petrie was in Camden at the invitation of the Camden, Hope, Lincolnville and Rockport.
"Transparency is crucial to success of this," said Petrie, "You are plowing some new turf for Maine."
Petrie was speaking to approximately 30 citizens who gathered April 30 in the Tucker Room at the Camden Opera House at a joint gathering of the towns' select board members and town managers. It was billed as a learning event.
"This is an opportunity to ask questions," said Camden Select Board Chairman Martin Cates, at the outset of the meeting. "We are not laying out proposals. We are here to do some learning, so we decide what we want."
The towns have been discussing EMS since last fall, when Camden First Aid Association informed them that the nonprofit faced a serious financial situation. Camden First Aid has been providing ambulance service to the towns in one form or another for the past 77 years. While originally it was part of the Camden Fire Department, it became a nonprofit in the 1990s, and most recently was contracting individually with the towns for nominal annual contributions.
But last winter, the select boards heard just how drastic the organization's fiscal outlook had become. On Feb. 27, town officials at a joint meeting were told that Camden First Aid needed $407,000 this coming year to meet budget, up from the $56,000 requested collectively from the four towns last year.
To complicate the issue, the request came just as the four towns were beginning to put their budgets together for their own fiscal year 2013-2014. Those budgets are to be approved at town meetings in June, but the process of considering the EMS price increases began to be debated in March by budget committees and select boards. The Camden-based nonprofit laid out its requests, seeking $174,000 from Camden, $129,000 from Rockport, $77,000 from Lincolnville and $27,000 from Hope.
While Camden First Aid submitted its contribution requests, the town select boards likewise decided to conduct due diligence for their taxpayers. They directed their town managers and administrators to circulate a request for proposals from interested EMS providers. Four companies responded: Camden First Aid, Delta Ambulance, Northeast Mobile Health Services and Sterling Emergency Medical Services, the latter of which bid only on Hope. (Currently, Hope is serviced by two EMS providers, Union Ambulance to the west of Alfred Lake Road, and Camden First Aid to the east).
Then, the towns collectively created an EMS Review Committee comprising two selectmen from each town, the town manager/administrators, and interested citizens. The committee consists of:
Rockport: Select Board members Geoff Parker and Ken McKinley, and Interim Town Manager Roger Moody.
Camden: Select Board members Martin Cates and John French, and Town Manager Patricia Finnegan.
Hope: Selectman Eric Campbell, Budget Committee member Bill Pearse, Jr., and Town Administrator Jon Duke.
Lincolnville: Selectman Jason Trundy, citizen Jim Sinclair, and Town Administrator David Kinney.
The committee began its work today, May 2, when it met in executive session at the Camden Town Office to begin reviewing the bids (see sidebar). The complete bids are also posted above as PDFs.
"As we have tried to work we wanted to be flexible," said Roger Moody. "Each town has its own needs and concerns. This will give the boards, and this review team, options to pursue. We will decide who will be interviewed. There will be a summary and a recommendation made."
But reviewing the bids is only one aspect of the committee's discussion. Members will also explore other models, such as quasi-municipal EMS systems (something that Camden First Aid has also indicated a willingness to explore). They might talk about an even more regional structure, such as a county-run EMS system, or municipal, or even hospital-based systems, all of which can exist with paid fulltime staff, or per diem staff, or with volunteers, or a combination thereof, said Petrie.
"The type has a lot to do with call volume," said Petrie. "People need to pay for readiness. You pay a cost every year to have a group of people respond to fires. But you don't want them not to be there. Same is true of EMS."
He cited the example of Washington County EMS Authority.
"It is a great example of multiple communities, but it fell apart because they were not communicating," he said. "You have to be working for the common good."
Petrie was at the meeting as an independent advisor, and will be advising the EMS Review Committee as such.
“This is an important topic for our communities and one we haven't talked about in many, many years,” said Patricia Finnigan, Camden's town manager. "The citizens have to be involved in this. We have to think about the services we have had so far, and what we might want to see. This next month, we are also giving information to citizens. Select boards will make decisions but taxpayers have to approve."
The decision is not just a matter of going with the cheapest ambulance service.
"We all know that it is complicated in terms of the medical issues," said Finnigan. "But it is also really simple. Because we know that when we have an emergency we want to know who is going to show up and take care of us. But how are we going to get to that point?"
• Camden First Aid seeking $407,000 in funding from four-town taxpayers
• Hope gives preliminary nod to Camden First Aid; talks continue with four towns
• Camden, Lincolnville, Rockport to circulate requests for emergency services proposals
Petrie outlined for the group the EMS levels of licensing and permitting, such as the difference between emergency medical responders, who can provide basic care and stabilize patients, but can't be alone in an ambulance with a patient, and emergency medical technicians, who assist with medications, childbirth, can splint and care to allergic reactions. He also described the role of paramedics, who can tend to cardiac arrests and conduct surgery.
He also described the fiscal realities of running EMS, telling the group that to support one paramedic on staff, 24 hours a day, seven days a week, a service, in general, needs to make 2,000 transports a year to pay for it.
And transports — taking patients from home to hospitals, and from hospitals to other hospitals — are essential to keeping EMS providers afloat these days.
“If you get into non-emergency transports, with a distance of five miles or less to a hospital, there is a lot less revenue,” he said. "Local intown transfer is a lot less of a money generator, unlike Pen Bay Medical Center to Portland or Pen Bay to Boston.”
A community could staff EMS like firefighters, but to make it pay, a provider needs one call every two hours.
"That's a lot of manpower and overhead," he said. "Very few ever hit .5. We just don't hit that kind of efficiency."
“What are consequences if you don't have a paramedic,” asked Roger Moody.
Petrie described Washington County's EMS system, which has few paramedics, compared to cities in Southern Maine, with larger, wealthier communities that are staffed with paramedics.
“Call volume plays heavily into what makes us tick,” Petrie said. “We have ambulance services doing 150 calls a year.”
But, he said, those rural communities thinking about foregoing having their own ambulance service have to confront another problem: “People who live there would wait an hour and half to wait for a response.”
He cited the types of communities that can afford expensive emergency medical service, such as the volunteer Freeport Fire and Rescue, but whose buildings and equipment has been subsidized by L.L. Bean.
It has, he said: "a lot more people and money. Drive north, buildings are converted garages and the communities have older equipment."
“Towns can make a decision that they really only want EMTs,” he said. “Most places that look for ambulance service strive to provide highest level of care for those patients who need it.”
But, he said, there are innovative ways of moving the EMS model forward, suggesting the staffing of a paramedic at a hospital, who goes out to those crises in a “fly car.” When they are not racing to emergencies, those paramedics serve other functions at the hospital.
Or, he continued, an ambulance service itself could adopt community paramedicine practices, which expand the role of paramedics into other services besides emergency response.
"Figure out how to serve our communities in other ways," he said.
Community paramedics could work with home health, he said. This could help keep patients at home, out of the hospital, and thus keep hospital costs down. They could work with nursing homes — as simple as taking blood pressure, he said — and just by interacting with them, cut EMS costs.
He pointed to two successful models. Emergency Health Services, a division of the Nova Scotia Department of Health and Wellness. And, Minnesota's Community Paramedic initiative.
"The goal is better patient care and better patient management," he said.
"Establish a relationship with hospitals," he said. "Ask them, what can I do to help you?"
He described such a relationship in Dallas involving five hospitals that trained paramedics, at a cost of $80,000, to tend to medical equipment used by patients at home to clear lungs.
"This saved $5 to $10 million, and reduced the average stay in hospital by three to five days," said. "Put Rick in a fly car, have him do community checks. When an emeregency comes in that needs me, I respond."
He left with some parting words: "You have to pay attention. What can an EMS service do in the community to help solidify what they are doing? We are in the most in intimate level in peoples' live. You have to hold EMS accountable. You've got to figure out a way to work it."
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