Changes Coming to EMS Service

Is a Full Dialogue Happening?

originally published May 7, 2008

During the time of year when the Athens-Clarke County (ACC) government formulates its budget for the coming fiscal year - and in a year when Mayor Davison has proposed the first millage rate hike in many years in order to keep pace with rising costs across the board - there’s been something of a background conversation going on about an entirely new expense that the local government might, at some point, be compelled to take on: some or all of the cost of providing emergency medical services (i.e., ambulance services) to local citizens. The conversation - as most of the people involved frequently refer to it - began in February, when a group of administrators from both Athens Regional Medical Center (ARMC) and St. Mary’s hospital went together to Mayor Davison and ACC Manager Alan Reddish to, in the words of ARMC spokeswoman Elaine Cook, “begin the discussion.”

That meeting served primarily as a signal to the ACC officials that, for financial reasons, the hospitals needed to begin exploring their options insofar as changing the structure of the emergency medical services (EMS) provision goes. One of those options, of course, would be for the local government to get into the EMS business, either through helping to subsidize the hospitals’ continued provision of the service, or by taking over the service completely (and possibly incorporating it into the fire department), as some municipalities have. By all accounts, that initial conversation was just that - initial - and it didn’t necessarily get very far, perhaps mostly because of the grim financial picture of emergency medical services in the Athens-Clarke and Oconee Counties at the present time: ARMC and St. Mary’s administrators, who are working together closely on the EMS issue, estimate their combined annual losses in providing EMS to be near $2.5 million at this point.

“Our response,” Reddish says, regarding that initial February conversation, “was that it’s a little odd that we’d be asked to take [on] a service that was already running at a deficit.” Why has the EMS business become such a losing proposition, financially speaking? In part because of rising costs in healthcare in general, and because of basic rising costs in areas like fuel. Historically (that is, in the last 40 years or so in Athens, since hospitals took it over from funeral homes), hospitals have supported EMS and provided it as a part of their services, despite it often not operating at a profit. Far more acute, though, is a massive ongoing deficit - just like that experienced regularly by doctors - in reimbursements from federal health coverage programs to ambulance services in general.

“The cuts in reimbursements for emergency medical services, really from Medicaid and Medicare, have been the problem,” says St. Mary’s hospital spokesman Avery McClean. “Those reimbursements are going down while your costs are going up, so that’s not a good formula.” Those “significant cuts in reimbursements,” ARMC’s Cook says, have been particularly large in the last five years, making the business of running ambulances less and less sustainable with each passing year. There is, of course, a third option besides local government subsidies or a government-based service: contracting with a private company to provide the service. All three set-ups appear in communities across the state (while entirely hospital-based and -funded service like that presently in Athens is, apparently, rare nowadays).

Seeking the Best Route

According to Cook, plenty of hospitals have switched to contracting with private, for-profit companies for ambulance service “with great success.” She cites major hospitals in Georgia cities like Columbus and Macon, and says that they’ve had “very good experiences” with the larger private services - those being the only ones that local hospitals would entertain contracting with.

But Sam Rafal, a local schoolteacher who has been a certified emergency medical technician for 20 years and works as such (not for pay) from time to time as the need arises, says it’s worth making a full examination of the level of care - as well as the prospect of a need for subsidies - that Athens could expect with a for-profit EMS company. If the hospitals can’t run the services without massive deficits, he asks, how could a for-profit private company make it work while maintaining the same level of care that Athens currently enjoys?

That’s one point on which hospital administrators, Athens-Clarke officials and Rafal - as well as local paramedic David Brooks - all agree: the level of service and quality of care in Athens and Oconee counties presently are very high. All agree, also, that keeping the same level of service in the future is a must. “But among those,” says ACC District 5 Commissioner David Lynn, “there’s a difference of opinion.” Brooks, for example, approaches the issue from the perspective of someone who currently runs a long-distance medical transportation company (which, he says, does business with neither local hospital). He also has worked as a paramedic under all three potential arrangements. In the 1980s and early ’90s, he was a paramedic at St. Mary’s; then he was a paramedic for Gwinnett County, which funds EMS completely and includes it in its fire department. Then, in the late ’90s, Brooks worked for a for-profit company that, he says - in a nightmare scenario for a local government - took over EMS in Catoosa County, GA only to very quickly ask for a large government subsidy. In the end, a neighboring county’s hospital took over Catoosa’s coverage. And, Brooks argues, for-profit companies often don’t have the high level of training and employee recruitment as hospital and government services do, nor the cutting-edge, expensive equipment that’s as new as theirs: “You can’t look at two ambulances and say, ’Well, it’s a licensed ambulance from [the state Department of Human Resources]; everything’s the same.’ And they’re not,” Brooks says.

Even if a situation like the Catoosa County tale that Brooks warns of is rare, though, it remains unclear whether a for-profit EMS company operating in Athens-Clarke and Oconee counties would require a subsidy in order to maintain the area’s current level of service or not. And while Rafal is doubtful of the latter, his primary goal, by far, in taking action on the issue is to encourage a conversation that pursues a clear understanding among all parties.

Any Real Dialogue?

“We may lose our hospital-based service without even having had a constructive discussion between the hospitals and the county commission,” he says. (Hence, simply fostering a full dialogue is the purpose of an online petition Rafal has created; interested citizens can email him at srafal@bellsouth.net to learn more.) Via a “constructive discussion,” Rafal hopes the Athens-Clarke and Oconee governments might at least assess what options might be most cost-effective (assuming that they will have to pitch in), ranging from subsidizing hospitals’ continued service to the very expensive prospect of taking over the services. He even suggests an independent audit to determine which costs associated with EMS are necessary, and which might be flexible. Meanwhile, hospital administrators are keeping in mind the now jittery but dearly-held - and, by all accounts, first-rate - staffers in their EMS programs, a motivation to work towards a resolution that at least gives those employees a clear picture of their future. Also, some accuse interested citizens of having a financial self-interest in the outcome of the debate, though Rafal and Brooks insist they have none.

And with the ACC Mayor and Commission ready soon to adopt a budget that’s drawing fire from homeowners upset with tax increases, the idea of either taking over or subsidizing a deficit-prone service - one which hospitals historically ran, and which has been all but abandoned, financially speaking, by federal government programs - is obviously unappealing. Still, while Reddish ponders a tight budget and awaits further news from hospital administrators - who simultaneously are exploring all options and preparing to look at bids from for-profit companies this summer - the larger question of what services belong in the government realm may go unaddressed.

The hospitals, Commissioner Lynn says, “haven’t approached the commission at all; we haven’t had a discussion in a formal sense.” Neither he nor Commissioner Andy Herod, who is also interested in the issue, is particularly up to speed on details of the process at this point, since the formal discussion Lynn mentions hasn’t taken place.

“If it’s a market failure,” Lynn says, “then that’s a proper role, for local government to provide literally a life-or-death service.” He adds, “Something tells me in the long term this is going to require stronger local government participation than we’re seeing now.” In that case, he says, he’d want to explore ways to keep costs down, perhaps by creating some kind of regional EMS system, for example. He notes too that approaches like Gwinnett’s, with EMS inside the county fire department, might make sense. Changes to that system were common in the '90s, he says. And by way of background, Lynn says, fire suppression calls have gone down with changes in building technology in recent years, while medical emergency calls have gone up. “My gut reaction is one day Clarke will have to take over that service, like they have in Jackson County, Gwinnett County…”

Lynn adds, “In the long run, this is a discussion we need to be having.” Rafal’s concern is that, with hospitals ready to stop the financial bleeding, a change in policy may be made without elected officials ever having that discussion. “It’s a lot of money,” he says, “but it may end up being more money if we don’t talk.”

Ben Emanuel

ben@flagpole.com