2026
CALEXICO
FIRE DEPARTMENT
EMS VALUATION &
OPERATIONAL ANALYSIS
JUNE 2026
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT i
TABLE OF CONTENTS
Table of Contents..................................................................................................................i Acknowledgments ..............................................................................................................iii Executive Summary ............................................................................................................iv SECTION I: EVALUATION OF THE EMS SYSTEM................................................................1 Overview of the Community & EMS System............................................................................2 Description of the City of Calexico.............................................................................................. 2 Fire and EMS Services................................................................................................................ 4 EMS Administration and Medical Direction ................................................................................. 4 Ground and Air Emergency Medical Services .............................................................................. 5 Capital Facilities & Equipment..............................................................................................6 Facilities.................................................................................................................................... 6 Capital Medical Equipment........................................................................................................ 7 Service Delivery & Performance............................................................................................8 Historical Service Delivery & Performance .................................................................................. 8 Service Demand ........................................................................................................................ 8 EMS Service Demand................................................................................................................. 9 Temporal Variation .................................................................................................................. 12 High Incident Locations ........................................................................................................... 14 Response Performance............................................................................................................ 14 Time Performance Standards ................................................................................................... 16 Performance Discussion.......................................................................................................... 18 Projected Population Growth & Future Service Demand ................................................................ 19 Service Demand Projections .................................................................................................... 19 SECTION II: EMS SYSTEM VALUATION ..........................................................................21 Financial Analysis of EMS Transport Services....................................................................... 22 Determining the Value of the System ........................................................................................ 22 Strategize Optimal Transport Rates .......................................................................................... 26 Current Patient Transport Fees and Payor Mix........................................................................... 28 Ambulance Enterprise Fund..................................................................................................... 33 Resource Needs and Workload Assessment........................................................................ 37 Unit Hour Utilization & Time on Task ......................................................................................... 37 Projected Unit Deployment ...................................................................................................... 39 Costs of the EMS System.................................................................................................... 44 Personnel Costs ...................................................................................................................... 44 EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT ii
Salary...................................................................................................................................... 46 Benefits................................................................................................................................... 48 Personnel Costs ...................................................................................................................... 49 Overhead Costs....................................................................................................................... 50 Cost Recovery ................................................................................................................... 53 Analysis of Potential Revenue Streams ..................................................................................... 53 Federal Reimbursement Programs ........................................................................................... 54 First Responder Fee................................................................................................................. 57 Cost of Readiness and System Efficiency.................................................................................. 58 Legal and Policy Considerations............................................................................................... 58 Cost Recovery Methodology..................................................................................................... 59 SECTION III: EMS SYSTEM DELIVERY MODELING...........................................................61 Deployment Modeling ........................................................................................................ 62 Comparative Analysis of Delivery Models.................................................................................. 63 Summary of Transportation Models.......................................................................................... 67 SECTION IV: FEASIBILITY, OBSERVATIONS, AND RECOMMENDATIONS..........................68 System Feasibility, Considerations, & Recommendations .................................................... 69 Feasibility................................................................................................................................ 69 ConsIderations........................................................................................................................ 70 Recommendations .................................................................................................................. 73 SECTION V: APPENDIX.................................................................................................76 Appendix A: Table of Figures ............................................................................................... 77 EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT iii
ACKNOWLEDGMENTS
AP Triton wishes to extend its sincere appreciation to each of those individuals and organizations whose contributions and assistance made this project possible.
Our sincere appreciation is extended to each of you!
CALEXICO FIRE DEPARTMENT
Juan Contreras
Fire Chief
Joshua Paddock
Engineer
Esteban Hernandez
Firefighter
Inez Kelly
Administrative Assistant
We also extend our deep appreciation to each of the firefighters, officers, support staff, and elected and appointed officials who serve the citizens and visitors of Calexico.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT iv
EXECUTIVE SUMMARY
AP Triton was contracted to conduct an EMS evaluation and optimization study for the Calexico Fire Department (CFD), assessing the operational aspects of the City’s ambulance service area. The primary objective of this study is to provide actionable recommendations to help the City of Calexico structure its ambulance service in a fiscally sustainable manner.
While the Calexico Fire Department is an all-hazards response agency, this study focused specifically on the EMS program. As part of the evaluation, AP Triton provided input on deployment models that may enhance service relative to current levels and represent the most sustainable approach to serving residents and visitors of the City of Calexico.
During the course of the study, AP Triton identified key findings that present opportunities for CFD to strengthen EMS system delivery across the community. Given the limited scope of this engagement, these findings are not addressed in exhaustive detail; however, AP Triton would welcome the opportunity to support a broader assessment of the organization’s public safety services in the future.
Additional considerations were developed to supplement this study and assist CFD in identifying factors that may affect the organization’s current and future needs. One recurring gap identified during the process highlighted the potential value of a formal strategic planning effort. A coordinated investment by CFD, the City of Calexico, and community stakeholders would support the development of a structured roadmap and gap analysis to address the evolving challenges and needs of public safety.
Finally, AP Triton issued a recommendation based on the information provided and its data synthesis.
Because historical records limited the ability to reliably extract key variables (e.g., response characteristics, patient information, and incident type), the preferred optimization approach was determined to be a hybrid model that incorporates both sworn and non-sworn personnel. While this option may yield cost savings for the City and CFD, the final decision should also consider the report’s broader findings to support cultural alignment and organizational stability.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 1 Section I:
Evaluation of the EMS
System
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 2 OVERVIEW OF THE
COMMUNITY & EMS SYSTEM
DESCRIPTION OF THE CITY OF CALEXICO
The City of Calexico is located in the southeastern corner of Imperial County, directly along the U.S.– Mexico border, adjacent to Mexicali, Baja California. Calexico began as a tent city, established by the Imperial Land Company in 1899 and was incorporated in 1908. The City’s name is a blend of “California” and “Mexico,” reflecting its close geographic, economic, and cultural relationship with its neighboring Mexican city. The City’s development was closely tied to the transformation of desert land into fertile ground for year-round agriculture, thanks to irrigation projects like the Imperial Canal and the All-American Canal. Calexico serves as one of the primary border crossings between the United States and Mexico in the Imperial Valley region. Its location places it approximately 120 miles east of San Diego and about 230 miles southeast of Los Angeles, and the service area is approximately 8.6 square miles, making it a strategically important gateway for cross-border commerce, travel, and cultural exchange.
Calexico had a population of approximately 38,633 in 2020. 1 The City’s population density is high, and
it is characterized by a youthful median age and a vibrant mix of backgrounds. The cost of living is below the national average, and the City’s real estate market offers affordable options compared to other California cities. The City functions as part of a larger binational metropolitan area with Mexicali, which has a population exceeding one million people. This cross-border relationship significantly influences daily life, economics, and public safety operations within Calexico. The local economy is closely tied to agriculture in the surrounding Imperial Valley, cross-border retail and services, and international trade activities facilitated by the Calexico West and Calexico East Ports of Entry. The City experiences a high volume of cross-border traffic each day, contributing to its role as a regional hub despite its small geographic footprint.
1 U.S. Census, available online at: https://www.census.gov/quickfacts/fact/table/calexicocitycalifornia.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 3 Figure 1: City of Calexico Data2
2020 U.S. Census
Population 38,744
Persons <5 years 7.6%
Persons <18 years 28.3%
Persons > 65 years 52.7%
Households 9,918
Persons per Household 3.87%
Household Income (median) $50,021
People in Poverty 21%
Within city limits is Calexico International Airport, the U.S. Customs and Border Protection checkpoint for private passenger and air-cargo flights entering the U.S. from Mexico. Private charter services are also available there. General aviation facilities and scheduled passenger and air-cargo service to San Diego International Airport, Bob Hope Airport in Burbank, and other points are available at Imperial County Airport (Boley Field) located 17 miles north.
Calexico offers a blend of American and Mexican cultures, with a small-town lifestyle and sunny climate year-round. Outdoor recreation is popular, including golfing, water sports, hunting, fishing, and hiking. The City’s location allows easy access to the beaches of San Diego and Baja California, as well as cultural and entertainment opportunities in Mexicali. Residents enjoy a variety of dining options and community events that reflect the city’s diverse heritage.
From a municipal services perspective, Calexico faces challenges common to small border communities. These include fluctuating population levels due to daily cross-border movement, economic disparities, and infrastructure demands related to international travel and commerce. At the same time, the City’s location provides unique opportunities for regional collaboration with neighboring jurisdictions and federal agencies responsible for border operations. These factors collectively shape the environment in which the Calexico Fire Department operates and influence the demand for emergency medical services, fire protection, and cross-border emergency coordination. 2 Ibid.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 4 FIRE AND EMS SERVICES
Fire protection and emergency medical services within the City of Calexico are provided by the Calexico Fire Department (CFD), a career department responsible for delivering all-risk emergency response services to residents, businesses, and visitors. CFD was formed shortly after the incorporation of the city in 1908. The Department operates as a municipal agency under the authority of the City Manager and is tasked with protecting life and property through fire suppression, rescue services, hazardous materials response, fire prevention, and public education programs. The Fire Chief serves at the pleasure of the City Manager and is responsible for the supervision and leadership of all fire department members and employees. In addition to traditional fire protection responsibilities, the Department plays a leading role in the delivery of pre-hospital emergency medical services (EMS) within the City.
The Calexico Fire Department provides Advanced Life Support (ALS) first-response medical services and responds to medical emergencies throughout the City. For medical calls, the Department typically deploys at least one fire apparatus and an ALS fire-based paramedic transport unit to ensure adequate personnel are available to provide patient care, scene management, and safe patient movement. This model allows firefighters and paramedics to deliver rapid pre-hospital assessment, stabilization, and treatment prior to transport to a receiving hospital. EMS calls represent a sizable portion of overall emergency responses, reflecting national trends in which fire departments serve as primary first responders for medical emergencies. CFD is the exclusive transport provider for the City.
Operationally, the Department functions as a small but fully integrated municipal fire department serving a community of nearly 40,000 residents within a compact urban area along the U.S.–Mexico border. The CFD operates from two fire stations staffed by career personnel. Fire companies are staffed with trained firefighters, and minimally certified as emergency medical technicians (EMTs) or paramedics, enabling the Department to provide advanced medical care and fire suppression services simultaneously. Through mutual aid agreements and coordination with regional agencies, the CFD can access additional specialized resources when responding to large-scale incidents or disasters affecting the broader Imperial Valley region.
EMS ADMINISTRATION AND MEDICAL DIRECTION
Emergency medical services (EMS) within the City of Calexico operate under the authority of the Imperial County Emergency Medical Services Agency (ICEMSA), the designated Local EMS Agency (LEMSA) for Imperial County. ICEMSA is responsible for establishing countywide EMS policies, clinical protocols, quality improvement requirements, ambulance system coordination, and provider certification standards in accordance with regulations established by the California Emergency Medical Services Authority.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 5 Medical direction is provided through the Imperial County EMS Medical Director, Dr. Katherine Staats, who oversees clinical treatment protocols, paramedic scope of practice, continuing education requirements, and systemwide quality assurance and improvement activities. The Medical Director works collaboratively with EMS providers, hospitals, and public safety agencies to maintain coordinated prehospital patient care throughout the county.
Under this framework, local agencies such as the Calexico Fire Department operate as field EMS providers responsible for delivering prehospital emergency medical care consistent with countyestablished policies and protocols while maintaining responsibility for their own staffing, training, and operational deployment.
GROUND AND AIR EMERGENCY MEDICAL SERVICES
Ground ambulance transport services within the City of Calexico are coordinated through the Imperial County EMS system. Authorized ambulance providers deliver Advanced Life Support (ALS) and Basic Life Support (BLS) transport services in coordination with local fire department first responders.
Ambulances are staffed by paramedics and EMTs who provide patient stabilization and transport to appropriate receiving hospitals in accordance with established destination and treatment protocols.
The Calexico Fire Department serves as the City’s primary fire and medical first-response agency, providing rapid on-scene patient assessment, stabilization, and life-saving interventions prior to ambulance transport. Fire department personnel are trained as EMTs and paramedics and operate under protocols established by the county EMS agency and Medical Director.
Air medical transport services supplement ground EMS resources for critically ill or injured patients requiring rapid transport or specialty care unavailable within the immediate area. Helicopter air ambulance providers, including Reach and Mercy Air, are utilized when transport times are excessive, advanced critical care capabilities are required, or transport to higher-level trauma centers outside Imperial County is necessary. These aircraft are staffed by flight nurses and flight paramedics and operate in coordination with the county EMS system and regional trauma networks.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 6 CAPITAL FACILITIES & EQUIPMENT
FACILITIES
Calexico Fire Department (CFD) provides comprehensive fire, EMS, and life safety services from two strategically located locations, ensuring rapid response across the city, with a current Insurance Services Office (ISO) rating of Class 3. The following figure shows these locations.
Figure 2: CFD Service Locations for the Community
Operation Location
Fire Administration 415 E. 4th Street, Calexico, CA 92231 Fire Station 1 430 E. 5th Street, Calexico, CA 92231
Fire Station 2 900 Grant Street, Calexico, Ca. 92231
Fire Station 1 Overview
Facility Description
Station 1 was constructed in 2022 and is in excellent condition. The facility encompasses a total of 9,006 square feet and includes eight bedrooms to accommodate personnel.
Staffing and Personnel
Station 1 is staffed by a combination of ALS and BLS personnel across multiple ranks and assignments.
The station maintains a daily minimum staffing level of seven personnel.
Figure 3: Fire Station 1 Facility Review
Fire/EMS Apparatus Staffing and EMS Level of Service
Engine 1 (3811) 3/ALS*
Rescue 1 (2670) 2/ALS*
Rescue 2 (2675) 2/ALS*
*Advanced Life Support (ALS) status is staffing dependent Fire Station 2 Overview
Facility Description
Station 2 was originally constructed in 1989 and has undergone recent remodeling to enhance its operational capabilities and living spaces. The station encompasses a total area of 2,600 square feet and includes three bedrooms to accommodate personnel during their shifts.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 7 Staffing and Personnel
Station 2 is staffed by a combination of Advanced Life Support (ALS) and Basic Life Support (BLS) personnel across multiple ranks and assignments. The station maintains a daily minimum staffing level of three personnel to support adequate emergency response coverage and operational readiness.
Figure 4: Fire Station 2 Facility Review
Fire/EMS Apparatus Staffing and EMS Level of Service
Engine 2 (3822) 3/ALS*
*Advanced Life Support (ALS) status is staffing dependent For purposes of this study, and consistent with the project scope focused on EMS delivery and future transport services, the information presented in this report emphasizes emergency medical services response capabilities and administrative capacity. Accordingly, this report does not provide a comprehensive evaluation of all Calexico Fire Department facilities, operations, or overall response capabilities.
CAPITAL MEDICAL EQUIPMENT
Emergency ambulance services within CFD’s current service area are provided by the Department with two full-time transport ambulance units. All durable medical equipment, as well as BLS and ALS supplies, medications, and narcotics, are provided with approval from ICEMSA in accordance with current agency policy.
CFD reports a cache of ALS and BLS major equipment necessary for first response EMS service delivery to the community. These supplies and equipment should be taken into consideration as any changes are evaluated, including depreciating assets that could incur significant capital replacement costs in the future fiscal budget years.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 8 SERVICE DELIVERY & PERFORMANCE
HISTORICAL SERVICE DELIVERY & PERFORMANCE
An important indicator of system effectiveness is the alignment between available resources and the actual utilization of services. For Calexico Fire Department (CFD), this requires maintaining a careful balance between fiscal responsibility and the operational demands associated with delivering timely, high-quality emergency medical services. Over- or under-allocation of resources can have significant consequences, either resulting in unnecessary expenditures or diminished service performance and increased response times.
Accordingly, the following section provides a comprehensive statistical analysis of the EMS service delivery system overseen by CFD. This analysis examines call volume, unit utilization, temporal demand patterns, and response performance metrics to evaluate how effectively current resources are meeting community needs. The intent is to identify strengths, gaps, and opportunities for optimization to support data-driven decision-making and long-term EMS system sustainability.
SERVICE DEMAND
The following figure is a graphic illustration comparing the difference in EMS incident volumes annually between 2021–2025. The decrease in incidents starting in 2022 is likely contributed to the COVID-19 pandemic and immigration policy changes—a pattern that has been seen in systems throughout the U.S.
Figure 5: CFD Annual Responses (2025)
4,315
4,220
4,106
3,911
4,012
3,600
3,700
3,800
3,900
4,000
4,100
4,200
4,300
4,400
2021 2022 2023 2024 2025
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 9 EMS SERVICE DEMAND
The total for EMS incidents within the study area was approximately 3,795 documented patients for 2025. The following figure shows a breakdown of the top 90% of medical emergency incidents based on the available data.
Figure 6: CFD EMS Service Demand (2025)
The criticality shown in the previous figure supports the necessity of ALS response. Additionally, the analysis supports consideration for adding a basic life support (BLS) component to the system. Many of the above incidents may be adequately cared for by a BLS crew, increasing the availability of paramedics for higher acuity incidents. Falls and non-motor vehicle traumatic events should also be evaluated for BLS transport to hospitals in the area.
17%
10%
9%
8%
7%
7%
4%
4%
3%
3%
2%
2%
2%
2%
2%
2%
1%
1%
1%
1%
1%
1%
0% 2% 4% 6% 8% 10% 12% 14% 16% 18%
Generalized Weakness
Abdominal Pain
Injury
Extremity Pain
No Complaints or Injury/Illness Noted
Acute Respiratory Distress (Dyspnea)
Altered Mental Status
Acute Pain, not elsewhere classified
Headache
Chest Pain, Other (Non-Cardiac)
Dizziness
Syncope / Fainting
Fever
Behavioral/psychiatric episode
Nausea
Hypertension
Stroke
Seizures without status epilepticus
Common Cold
Cardiac arrest
Vomiting
Pregnancy related conditions
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 10 The following figure shows the number of incidents in 2025 by each ambulance transport unit.
Figure 7: Ambulance Utilization (2025)
EMS Unit Number of
Incidents
Percentage of
Incidents
2670 1,729 44.5%
2675 1,679 43.2%
3811 246 6.3%
3822 164 4.2%
2672 50 1.3%
3821 19 0.5%
The above analysis demonstrates effective utilization of the frontline EMS units. The primary units are balanced and respond to 87.7% of the EMS incidents. Reserve units cover 12.3% of EMS incidents. The next figure shows the response mode to EMS incidents during 2025.
Figure 8: Calexico Fire Department Response Mode to EMS Incidents (2025) Response Mode No. of Calls % of Total
Initial Lights and Sirens, Downgraded to No Lights or Sirens 1 0.03% Lights and No Sirens 4 0.10%
Lights and Sirens 3,816 99.19%
No Lights or Sirens 26 0.68%
The prior figure highlights a potential opportunity for improvement related to the high utilization of emergent responses to medical incidents. One consideration is the possibility of inaccurate documentation within the patient care reporting (PCR) system. Another is the potential need to expand the use of emergency medical dispatching (EMD) protocols and further limit lights-and-sirens responses by the Calexico Fire Department to incidents requiring an emergent response.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 11 The final analysis of unit hour utilization looks at the calculated number of ambulances required to provide emergency services. The following figure shows the average number of ambulances each hour and by day of the week based on the 2025 incident data. The calculation is based on a .45 unit hour utilization.
Figure 9: Calculated Number of Ambulances by Day/Hour
Fire EMS Call Volume - Considering UHU
Sun Mon Tues Weds Thurs Fri Sat
12:00:00 AM 1.5 1.0 1.0 1.0 1.0 0.9 0.9
1:00:00 AM 1.0 0.8 0.8 0.6 0.6 0.8 0.8
2:00:00 AM 0.9 1.1 1.1 0.8 0.8 0.7 0.7
3:00:00 AM 1.2 0.9 0.9 0.6 0.6 0.8 0.8
4:00:00 AM 0.8 0.8 0.8 0.5 0.5 0.5 0.5
5:00:00 AM 0.8 1.0 1.0 0.9 0.9 0.8 0.8
6:00:00 AM 1.1 1.1 1.1 0.9 0.9 0.9 0.9
7:00:00 AM 1.0 1.5 1.5 1.2 1.2 1.3 1.3
8:00:00 AM 1.0 1.5 1.5 2.0 2.0 2.0 2.0
9:00:00 AM 1.5 2.2 2.2 2.3 2.3 2.4 2.4
10:00:00 AM 1.6 2.5 2.5 2.3 2.3 2.1 2.1
11:00:00 AM 1.8 2.1 2.1 1.8 1.8 2.4 2.4
12:00:00 PM 1.8 2.9 2.9 2.4 2.4 2.6 2.6
1:00:00 PM 1.4 2.3 2.3 2.8 2.8 2.4 2.4
2:00:00 PM 2.1 2.5 2.5 2.5 2.5 2.5 2.5
3:00:00 PM 1.5 2.6 2.6 2.1 2.1 2.3 2.3
4:00:00 PM 2.0 2.6 2.6 1.9 1.9 2.4 2.4
5:00:00 PM 2.1 2.4 2.4 2.3 2.3 1.6 1.6
6:00:00 PM 2.3 2.0 2.0 2.1 2.1 1.6 1.6
7:00:00 PM 2.0 1.9 1.9 2.0 2.0 1.9 1.9
8:00:00 PM 1.9 1.3 1.3 1.7 1.7 1.7 1.7
9:00:00 PM 1.2 1.8 1.8 1.7 1.7 1.8 1.8
10:00:00 PM 1.3 1.7 1.7 1.0 1.0 1.1 1.1
11:00:00 PM 1.5 1.2 1.2 1.0 1.0 1.2 1.2
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 12 TEMPORAL VARIATION
A temporal analysis of incidents reveals when the most significant service demand occurs. The following figures show how activity and demand change based on various time measurements. The analysis was calculated using 2025 data provided by CFD. The results are based on the total number of incidents.
Figure 10: Service Demand by Month (2025)
Calexico Fire Department EMS call volume remains consistent throughout the year. The lowest call volume was in November, with peak demands of 9.2% in May and October. There does not appear to be a need for seasonal up-staffing during a specific time of year.
8.6% 8.3%
7.7%
8.3%
9.2%
7.5%
8.5% 8.4%
8.9% 9.2%
7.1%
8.3%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 13 The following figure shows the call volume throughout the week. CFD has a very consistent service demand with a slight increase at the beginning of the week. This pattern limits the ability to schedule training and other required duties at a specific time during the week.
Figure 11: Service Demand by Day of the Week (2025)
The following figure illustrates the service demand by hour of the day from 2025. The pattern shows a specific increase in service demand in the middle of the day with peak periods between 9:00 am–6:00 pm.
Figure 12: Service Demand by Hour of the Day (2025)
0 100
200
300
400
500
600
700
Sunday Monday Tuesday Wednesday Thursday Friday Saturday 2025 Poly. (2025)
0 50
100
150
200
250
300
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 2025 2 per. Mov. Avg. (2025)
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 14 HIGH INCIDENT LOCATIONS
In addition to the temporal analysis, AP Triton conducted a spatial assessment to identify locations exhibiting repetitive and concentrated EMS service demand. This analysis focused on incident clustering at specific addresses and facilities to better understand patterns of recurring utilization and potential system stress points.
By examining incident frequency at the municipal address level, AP Triton was able to isolate highdemand locations that generate a disproportionate share of EMS responses. These locations often include healthcare facilities, senior living communities, high-density residential complexes, and other sites associated with increased medical need or service utilization. Identifying these patterns is critical for informing deployment strategies, targeted community risk reduction efforts, and potential partnerships aimed at mitigating repeat service demand.
The following figure illustrates the distribution of incident volume by municipal address, highlighting the locations with the highest frequency of EMS responses.
Figure 13: Incident Volume by Address (2025)
Address Incidents Type Percentage
300 W 2nd Street 615 Port of Entry Vehicle 15.8%
200 1st Street 493 Port of Entry Pedestrian 12.8%
420 E 5th Street 54 Police Station 1.4%
351 E Birch Street 34 Dialysis Center 0.9%
430 E 5th Street 28 CFD Station 1 0.7%
2540 Rockwood Avenue 25 Wal-Mart 0.6%
RESPONSE PERFORMANCE
An emergency services delivery system's most publicly visible component is response performance.
Policymakers and citizens want to know how quickly they can expect emergency services. Setting response standards based on averages is generally a poor indicator of performance. Most organizations measure performance on the 90th percentile compared with the National Fire Protection Association (NFPA) standards. For policymakers and citizens to make informed decisions concerning response performance, jurisdictions must record and report the various components of the jurisdiction’s current performance.
In analyzing response performance, AP Triton generates percentile measurements of response time performance. The use of percentile measurements using the response time components follows industry best practices recommendations.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 15 The “average” measure is a commonly used descriptive statistic called the data set's mean. The most important reason for not using the average for performance standards is that it may not accurately reflect the performance for the entire data set and may be skewed by outliers, especially in small data sets. One extremely good or bad value can skew the average for the whole data set.
Median measure is another acceptable method of analyzing performance. This method identifies the value in the middle of a data set and thus tends not to be as strongly influenced by data outliers.
Percentile measurements are a better measure of performance because they show that most of the data set has achieved a particular level of performance. The 90th percentile means that 10% of the values are more significant than the value stated, and all other data are at or below this level. This can be compared to the desired performance objective to determine the degree of success in achieving the goal.
As this report progresses through the performance analysis, it is essential to remember that each response performance component is not cumulative. Each is analyzed as an individual component, and the point at which the fractal percentile is calculated exists in a set of data unto itself.
The response time continuum—the time between when the caller dials 911 and when assistance arrives—is comprised of several components:
• Alarm Processing Time: The time interval from receiving the alarm at the primary Public Safety Answering Point (PSAP) until the beginning of the transmittal of the response information via voice or electronic means to emergency response facilities or the emergency response units (ERUs) in the field.
• Turnout Time: The time interval that begins when the emergency response facility and ERU notification process starts by either an audible alarm or visual annunciation or both and ends at the beginning point of travel time.
• Travel Time: The time interval begins when a unit is enroute to the emergency incident and ends when the unit arrives at the scene.
• Response Time: A combination of turnout time and travel time. This is the most frequently utilized measure of fire department response performance. • Total Response Time: Total Response Time is the time interval from receiving the alarm at the dispatch center to when the first emergency response unit initiates or intervenes to control the incident. For this report, Total Response Time will be defined as receipt of the alarm at the dispatch center until the arrival of the first fire department unit.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 16 Figure 14: Response Time Continuum
The definitions for each population category follow the Center for Public Safety Excellence standards for density: Urban (> 2,000 persons per square mile), Suburban (> 1,000 persons per square mile), and Rural (< 1,000 persons per square mile).
TIME PERFORMANCE STANDARDS
CFD’s response performance was compared to the national consensus standard for response performance found in the NFPA Standard 1750: Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments, 2020 Edition. In addition, the dispatch center’s performance was compared to standards found in the NFPA’s Standard 1221: Standard for the Installation, Maintenance, and Use of Emergency Services Communications Systems, 2019 Edition.
Call Turnout Travel Time
Response Time
Total Response Time
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 17 The following figure summarizes the performance standards used in this section to evaluate performance compared to NFPA 1750 standards.
Figure 15: Summary of Performance Goals
Incident Interval Performance Goal
911 call answer (time from the first ring to answer). Within 15 seconds, 90% of the time Within 20 seconds, 95% of the time
Call process time (time from acceptance at the
dispatch center until notification of response
units).
Within 60 seconds, 90% of the time, for high
acuity incidents.
Incidents requiring EMD or special
assistance, 90 seconds, 90% of the time.
All incidents, 120 seconds 99% of the time.
Turnout time (time from notification of response
personnel until the initiation of movement towards
the incident).
Within 60 seconds, 90% of the time (EMS)
Within 80 Seconds, 90% of the time (Fire)
First unit travel time (time from initiation of
response until the arrival of the first unit at the
incident).
Within 4 minutes, 90% of the time
First unit response time (time from dispatch until
the arrival of the first unit at the incident).
Within 5 minutes, 90% of the time (EMS)
Within 5 minutes, 20 seconds, 90% of the
time (Fire)
Full effective response force travel time (time from
dispatch until all units initially dispatched arrive at the incident. Response resources needed for a
moderate risk building fire are used for the
evaluation).
Within 8 minutes, 90% of the time
The following figure shows CFD’s overall performance for all EMS incidents in 2025.
Figure 16: CFD Response Performance 90th Percentile (2025) Call Processing Turn-out
Time Travel Time First Unit Response Time
ERF Total Response
Time
0:05:17 0:04:39 0:05:14 0:09:00 0:14:12
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 18 PERFORMANCE DISCUSSION
Calexico Fire Department’s performance analysis identifies opportunities for system improvement. As a priority, CFD should conduct a thorough review of data documentation processes to ensure that incidents are accurately entered into the computer-aided dispatch (CAD) system and correctly transferred into the patient care reporting (PCR) platform. Data integrity is critical, as all subsequent performance evaluations and system decisions rely on the accuracy of this information.
While the analysis presented above was intended to focus on emergent responses, the previously identified rate of approximately 99% emergent incidents suggests that non-emergent events were likely included in the dataset. This misclassification may also be influencing other performance measures, including the extended crew turnout times. Refining the dataset to isolate true emergent responses will provide a more accurate representation of operational performance and may demonstrate improved turnout metrics.
Despite these data concerns, the average travel time of 5 minutes and 14 seconds reflects effective station placement and overall geographic coverage. This indicates that, from a deployment perspective, CFD is well-positioned to deliver timely response once units are enroute.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 19 PROJECTED POPULATION GROWTH & FUTURE SERVICE DEMAND
Population Growth Projections
According to the U.S. Census Bureau, the Calexico Fire Department and service response area around the city had a population of 38,633 in 2020. Over the past four years, there has been minimal population growth of approximately 3.5%, with the impact of the COVID-19 pandemic on future growth yet to be fully understood. Projections are based on historical data and projection software, as shown in the following figure.
Figure 17: Population Projections (2025–2030)
SERVICE DEMAND PROJECTIONS
To forecast future service demand, AP Triton utilized population projections for the Calexico Fire Department. Population tends to be a reliable indicator of service demand, with the current service demand per 1,000 people as a reference point for future service demand. The following service demand projections are based on an estimated population of 39,950.
Forecasting EMS service demand in Calexico presents unique challenges due to recent external influences, including the lingering effects of the COVID-19 pandemic and fluctuations associated with immigration policies that have significantly impacted call volume and service utilization. These factors have introduced variability that makes trend analysis less predictable than in more stable environments.
38,556 38,311 38,224
38,744
39,950
39,940
40,300
40,660
41,020
41,380
35,000
36,000
37,000
38,000
39,000
40,000
41,000
42,000
43,000
44,000
2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
Values Forecast Lower Confidence Bound Upper Confidence Bound EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 20 To develop reasonable projections, this analysis incorporates both local trends—particularly the observed increase in incident volume in 2025—and comparative data from similar jurisdictions across California. Based on these considerations, a conservative annual growth rate of approximately 3% has been applied over the next five years. The following figure illustrates the projected increase in service demand and provides a framework for evaluating future system capacity and resource needs.
Figure 18: Projected Service Demand (2026–2030)
4,315
4,220
4,106
3,911
4,012
4,012
4,052 4,072 4,093 4,113
3,700
3,800
3,900
4,000
4,100
4,200
4,300
4,400
2021 2022 2023 2024 2025 2026 2027 2028 2029
Current Current Predicted at .05%
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 21 Section II:
EMS System Valuation
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 22 FINANCIAL ANALYSIS OF
EMS TRANSPORT SERVICES
DETERMINING THE VALUE OF THE SYSTEM
Factors impact the value of an EMS system. The following section will help stakeholders, who are not intimately involved in the transport system, better understand the intricacies of valuing the system. The monetary value of the system primarily refers to the revenue that can be recognized from a given number of transports. There are no special or proprietary methods for generating revenue within an EMS system. The same general funding opportunities are available to all providers; however, significant differences in revenue recovery exist between agencies. These disparities are typically driven by performance in two key areas: billing practices and collections. Some agencies are simply more effective than others at accurately capturing, billing, and collecting reimbursement revenue.
Often, an agency gauges its success based on its collection rate. However, this is an inaccurate measure of overall success, as collection rates are just one aspect of effective EMS fiscal management. Key factors affecting billing and collections success include:
• Billing Policy
• Collection Rate
• Transport Rates (Charges)
• Documentation
• Billing Collector's Level of Effort
• Number of Transports
• Payor Mix
The value of Calexico’s EMS system is determined by both controllable and uncontrollable factors. The following elements can be actively managed to enhance system valuation:
• Billing Policy
• Collection Rate
• Transport Rates (Charges)
• Documentation
• Billing Collector's Level of Effort
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 23 However, certain elements are beyond the City's direct control:
• Number of Transports
• Payor Mix
Billing Policy
Establishing a comprehensive billing policy is a critical component of maximizing EMS system revenue and ensuring long-term financial sustainability. Several factors should be evaluated when developing a billing policy, including the overall philosophy and aggressiveness of the billing and collections process. While a more aggressive billing approach may increase collection rates, reimbursement ceilings established by Medicare, Medi-Cal, private insurance providers, and contracted payors ultimately limit the maximum recoverable revenue.
In addition, EMS transport demand is generally stable and driven by community need rather than ambulance availability. Increasing the number of ambulances in service does not necessarily result in increased patient transports or higher revenue generation. The expectation within an EMS system is that all patients requiring transport will receive appropriate care and transportation services. Although call volumes may fluctuate over time, most significant or seasonal variations are generally predictable and can be accounted for in financial planning and deployment strategies.
By carefully developing and implementing a well-defined billing policy that considers these operational and reimbursement factors, EMS providers can improve revenue recovery, strengthen financial performance, and support the continued sustainability of EMS operations.
Collection Policy
The collection policy is a critical component of the overall billing process and can significantly influence an EMS provider’s revenue recovery. Federal regulations require that all patients receive a bill for services rendered, prohibiting selective billing practices that target only certain patient groups or payor classes. As a result, collection practices must be applied consistently and in compliance with applicable healthcare regulations.
The level of aggressiveness in collection efforts typically reflects an agency’s overall business philosophy and approach to public service. Some providers pursue highly proactive collection strategies, including multiple billing notices, outside collection agencies, and legal recovery efforts, while others adopt a more moderate approach that places greater emphasis on community relations and financial hardship considerations.
A practical benchmark for collection efforts is whether the financial or operational return justifies the associated cost and effort. Collection activities should continue when they provide a reasonable likelihood of revenue recovery and should be reconsidered when the administrative expense, political sensitivity, or potential negative public impact outweighs the anticipated financial benefit.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 24 For public ambulance providers, it is essential to balance effective revenue recovery with community accountability, compassion, and public trust. A thoughtfully developed collection policy can help achieve this balance while supporting the long-term financial sustainability of EMS operations.
Transport Rate
Establishing an appropriate ambulance transport rate is essential to maintaining financial sustainability while ensuring fairness, consistency, and compliance with applicable regulations. All patients receiving transport services are billed regardless of insurance status or ability to pay, making a standardized and equitable billing structure critical for EMS providers.
Transport revenue is directly influenced by the percentage of incidents resulting in patient transport compared to total EMS responses. Although higher transport volumes generally generate increased revenue, transporting every patient is neither clinically appropriate nor operationally practical within an already strained healthcare system.
It is important to recognize that transport and non-transport decisions can have measurable financial impacts on the EMS system. For example, if two ambulance transport units each average one nontransport per shift, the system would forgo approximately 730 billable transports annually. Using a Medicare base reimbursement rate of approximately $522 per transport, this equates to an estimated annual revenue reduction of nearly $380,000. While maximizing transports should never become the objective of an EMS system, understanding these financial impacts allows agencies to evaluate and manage transport rates as part of overall system performance.
Cost recovery remains an important component of EMS system sustainability; however, financial considerations should never supersede sound clinical judgment or patient-centered care. Transport decisions must always be based on patient need, medical necessity, and provider assessment to maintain public trust, transparency, and professional credibility. Allowing financial incentives to drive transport decisions could undermine confidence in the EMS system and negatively impact community perception.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 25 Emergency transport reimbursement rates vary significantly by payor source. The following figure outlines estimated allowable reimbursement amounts under Medicare and Medi-Cal programs, which are typically adjusted annually.
Figure 19: Estimated Allowable Charges
Item Medicare Allowable Medi-Cal Allowable
Advanced Life Support (ALS) Rate $581.26* $1,158.10**
Basic Life Support (BLS) Rate $489.48* $1,158.10**
Mileage (per mile) $8.71 $3.19
Oxygen $0 $8.89
EKG $0 $14.46
Night Calls $0 $8.89
*This amount adds additional fees charged for mileage.
**This amount adds to the PP-GEMT payments.
While Medicare and Medi-Cal place limits on reimbursement, CFD should not be constrained by these figures when setting/updating transport fees. Expanding chargeable services and adjusting fees can improve cost recovery to cover the cost of providing the service. Additionally, private and commercial insurance, covering an estimated 17% of annually transported patients, offers further opportunities for increased revenue without impacting vulnerable populations.
Documentation
Electronic patient care reporting (ePCR) has significantly improved billing accuracy and speed.
However, many transport agencies fail to prioritize proper documentation training, leading to errors that delay or reduce reimbursements.
Accurate documentation is critical for securing appropriate reimbursement and tracking billable supplies. Medicare and Medi-Cal reimburse based on medical necessity rather than patient preference for hospital transport or the level of attendant. Errors in documentation can lead to lower reimbursement rates, such as billing an ALS service at the lower BLS rate. Proper documentation can significantly increase revenue where ALS services are provided.
For example, with an average reimbursement recovery of approximately $500 to $1,000 per transport, preventing just one transport denial per day due to incomplete or improper documentation could result in an additional $182,500 to $365,000 in annual revenue recovery—potentially enough to offset the cost of additional staffing or other operational enhancements.
The introduction of the ePCR has transformed billing by enabling instant access to patient records and streamlining reimbursement processes. However, ensuring thorough and accurate documentation remains a challenge. Common documentation deficiencies that can delay reimbursement include:
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 26 • Missing patient signatures
• Lack of medical necessity justification
• Incomplete transport mileage
• Failure to record billable procedures
Ensuring precise and timely documentation is vital for maximizing revenue and maintaining efficiency.
Billing Contractor's Level of Effort
Ambulance billing contractors play a crucial role in EMS revenue cycle management. Clearly defining a contractor’s expectations ensures efficient and accurate billing processes. The current contractor, Wittman Enterprises, LLC, is one of the largest ambulance billing contractors in California and performs operations for multiple large and small cities throughout the State.
Contractors should provide comprehensive services, including data entry, claim submission, insurance verification, coding, follow-up, and appeals. Claims must be processed promptly and accurately, incorporating all required documentation. Regular audits and quality checks are necessary to maintain billing accuracy, while open communication between the contractor and EMS provider ensures responsiveness and efficiency.
Revenue collection is heavily influenced by the provider’s billing policy. A weak or vague policy results in lower collection rates. Contracting with a third-party billing company, and the associated expenses, should be factored in operational costs. Most billing companies charge a percentage of collected revenue, though some use a fixed rate per bill. If a provider's collection policy is lax, billing contractors may demand a higher percentage to offset reduced collections.
Since EMS systems operate within a finite revenue cap, optimizing policies, training personnel, and monitoring service delivery can enhance collections. The advertised collection rate of billing companies alone does not reflect overall billing success.
Establishing clear expectations for billing contractors is essential to municipal EMS financial sustainability. A clear policy that specifies service scope, timelines, and accuracy requirements establishes guidelines for collaboration between contractors and EMS providers and helps define expectations related to revenue.
STRATEGIZE OPTIMAL TRANSPORT RATES
Developing strategies for setting optimal transport rates that balance cost recovery goals with community affordability is essential for a sustainable system. Below are four key strategies that could optimize transport rates:
1. Work closely with Wittman to optimize allowable charges. They are experts in the field. They can help the City understand how changes in billing can affect the community.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 27 2. Establish routine training with field personnel dealing with current documentation best practices. This is a service that Wittman (or any billing company) should provide free to the City.
3. Establish a compassionate collections policy that balances cost recovery goals with community affordability. The City should consider the actual reimbursement on collections performed.
4. Consider annual rate adjustments for inflation and service adjustments. This is a key factor as the city updates their delivery model.
Comparable Rate Structures
As the City reviews the optimal transport rates, it can take into consideration the rates of other cities and counties in Southern California. The following figure lists other systems (private/public) rates for transport services.
Figure 20: Transport Service rates
Jurisdiction ALS Rate BLS Rates Mileage
Los Angeles County ∼$3,408 ∼$2,276 ∼$30/mile
San Diego (City/Falck) ∼$2,820 - $3,151 ∼$2,379 - $2,546 ∼$43 - $46/mile Orange County ∼$2,900+ ∼$2,400+ ∼$25/mile
Inland Empire (Escondido) ∼$4,267 ∼$4,267 ∼$40/mile
201 Status & Rate Structure
Most EMS systems in California operate under rate structures established or regulated by their Local Emergency Medical Services Agency (LEMSA), which sets the maximum allowable ambulance transport rates within its jurisdiction. However, as a public agency operating under “201 rights” pursuant to California Health and Safety Code Division 2.5, the Calexico Fire Department is afforded certain exemptions from local rate-setting restrictions that typically apply to private ambulance providers.
“201 rights” refer to the authority granted to cities and fire districts that were providing prehospital emergency medical services prior to June 1, 1980, allowing them to continue and expand those services without being subject to exclusive operating area restrictions or certain LEMSA-imposed limitations applicable to private providers. This statutory authority provides public agencies with greater flexibility in establishing ambulance transport rates and operating EMS systems tailored to local community needs.
Calexico should periodically evaluate both local LEMSA-established rates and comparable ambulance transport rates charged by other public agencies throughout Southern California to ensure its fee structure remains competitive, defensible, and financially sustainable.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 28 In addition, understanding the community’s healthcare payor mix—including Medicare, Medi-Cal, private insurance, uninsured, and underinsured populations—is essential in developing a transport rate structure that balances fair patient billing practices with the long-term financial stability of the EMS system.
CURRENT PATIENT TRANSPORT FEES AND PAYOR MIX
Demographics of the Healthcare Payor Mix
The sustainability of the healthcare system is dependent on the payor mix within a given geographic area. In emergency transportation, payor mix and transport volume directly influence financial viability.
Understanding how payor demographics impact reimbursements is essential for assessing system value. Once these demographics are identified, estimated reimbursement rates can be determined.
There are four primary cost centers for medical charge reimbursement by responding agencies:
• Medicare: The primary healthcare coverage for individuals over 65. • Medicaid (Medi-Cal in California): A federal-state program providing healthcare coverage for low-income individuals and families (primarily those at or below 138% of the national poverty level).
• Commercial Insurance: Typically, employer-provided benefits but also available for independent purchase.
• Private Pay: Applies to uninsured individuals who pay for services out-of-pocket.
The proportion of system users from each of these categories determines potential reimbursement levels. For example, a system with a high concentration of commercially insured patients will achieve higher cost recovery rates than one with a large uninsured population.
Medicare
Medicare typically constitutes the largest segment of a system’s payor mix since it covers all individuals over 65. In Calexico, Medicare accounts for an estimated 53% of transported patients.
Medicare establishes a maximum allowable reimbursement amount for ambulance transports, currently estimated at approximately $650 for the base transport rate. Medicare typically reimburses 80% of the allowable amount, resulting in a direct payment of approximately $522, with the remaining balance considered the patient’s co-pay responsibility. Collection rates for patient co-pays vary by provider but are often estimated at approximately 30% recovery.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 29 As a result, even in systems where the billed transport charge averages $2,000 per incident, Medicare reimbursement remains limited to the established allowable amount of approximately $522, plus applicable mileage reimbursement. The remaining patient balance may generate an additional estimated recovery of approximately $130 through co-pay collections, depending on the provider’s collection practices and patient payor demographics.
Importantly, rate increases by the city do not impact Medicare reimbursement or patient co-pays. For instance, raising the charge to $5,000 would not change the payment structure, as Medicare’s capped reimbursement remains fixed. This constraint highlights the limited financial flexibility within the Medicare payor mix.
Medicaid/Medi-Cal
Medicaid, known as Medi-Cal in California, provides insurance for individuals living below the poverty line or those with significant disabilities. Some elderly individuals qualify for both Medicare and Medicaid and are referred to as “Medi-Medi’s.”
Like Medicare, Medi-Cal has a payment cap, currently set at approximately $118 (plus additions for mileage, oxygen, EKGs, and night calls), regardless of the service charge. However, additional federal enhancements increase total reimbursement to over $1,100. This enhancement program will be discussed in more detail later in this section.
Medi-Cal is the second-largest payor mix among transported patients in Calexico, comprising approximately 30% of total patient transport.
Commercial Insurance/Private Insurance
This payor mix category includes individuals with medical insurance obtained through employment, private purchase, or other means. Commercial insurance, also known as private insurance, consistently reimburses for ambulance transportation and first response fees, leading to an estimated reimbursement rate of 80%.
Commercial insurers typically cover the usual and customary payment based on billed charges. In Calexico, the average ALS transport charge is estimated at $1,702, with most commercial insurers reimbursing at least 80%, or approximately $1,360 per transport. The remainder of billable cost would be the responsibility of the patient.
Private Pay
This payor mix category includes individuals who do not qualify or have not applied for Medicare or Medi-Cal, or lack commercial insurance. It encompasses a broad economic range, from those with minimal income to those earning above-average wages. Traditionally, this group consists of individuals employed by small businesses that do not offer insurance or those who are self-employed.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 30 As a result, private pay patients vary widely in their ability to cover ambulance transportation and first responder fees. Select patients can afford the full cost, others may make partial payments through agreements, and some are unable to pay anything. Due to this economic diversity, the aggregate reimbursement rate for this group is estimated at 5% of total collections.
With the implementation of the Affordable Care Act (ACA) and Covered California, more individuals from this demographic continue to transition into insured categories.
Payor Mix & Transports
The figure below illustrates the estimated payor mix and transport volume for CFD. According to the data received from the City, the medical call volume was 3,887 in 2025. The total number of transports was 2,202. These figures will be used to estimate each payor mix’s transport volume for 2025.
Figure 21: Payor Mix Percentage & Transport Volume
Cost Center Percent of Transport Number of Transport
Medicare/Medicare HMO 53% 1,167
Medi-Cal/Medi-Cal HMO 30% 661
Commercial Insurance 9% 198
Self-Pay 8% 176
Total 100% 2,202
Figure 22: Payor Mix Percentage
Medicare
53%
Medi Cal
30%
Commercial
Insurance
9%
Self-Pay
8%
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 31 Applying the reimbursement formula to the payor mix requires adjustments for collection rates. One method utilizes a simple percentage-to-volume ratio. Variations in collection percentages across the payor mix depend on the stability of each cost center.
Medicare is the most stable cost center due to its well-defined eligibility requirements. Medicaid/MediCal and commercial insurance have slightly less stability, as enrollment fluctuates based on individual circumstances. Similarly, the private pay category is evolving as more individuals gain coverage through the ACA. Additionally, a portion of charges within each category is typically unbillable for a variety of reasons, the most common being lapsed coverage or unmet deductibles.
To estimate EMS system revenue, the current Calexico-authorized service rates should be evaluated.
The current rates are listed in the figure below indicating the base rates, mileage, and oxygen delivery charges. There are more standard and accepted charges that Calexico uses that were not included in this evaluation. This allows the valuation to be conservative in nature.
Figure 23: Authorized Calexico Fire Department Rates for Services Service ALS Rate BLS Rates
Base Rates $1,702.00 $1,473.00
Mileage (per mile) $12.96 $12.96
O2 Mask/Cannula $45.36 $45.36
The figure below represents the estimated average reimbursement per transport for each payor mix.
The Medi-Cal/Medi-Cal HMO reimbursement also includes the additional PP-GEMT payments that would be collected throughout the year. These average reimbursements will be used to value the system in combination with the number of transports in each payor mix.
Figure 24: Transportation Reimbursement Calculation Estimator Cost Center Estimated ALS
Recovery
Estimated BLS
Recovery
Medicare/Medicare HMO Reimbursement per Transport $522 $481 Medi-Cal/Medi-Cal HMO Reimbursement per Transport $1,158 $1,158 Commercial Insurance per Transport @ 80% $1,432 $1,248
Self/Private Pay per Transport @ 5% $89 $78
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 32 Using these standard revenue predictions, the reimbursement from each payor mix can be estimated based on transport in the system. For this modeling, the call volume is split into 50% ALS transport and 50% BLS transport. The following figure outlines the estimated net collection amounts, taking into consideration the estimated payments for the sustainability of the PP-GEMT program. Additional cost items, such as billing expenses, subcontracting fees, personnel salaries & benefits, and equipment costs will be discussed in the modeling section to evaluate the entirety of the system.
Figure 25: Estimated Payor Mix Reimbursement
Cost Center Number of
Transports
Estimated Gross
Billing
Estimated Net
Collection Amount
Medicare/Medicare HMO 1,167 $1,954,767 $584,884
Medi-Cal/Medi-Cal HMO 661 $1,106,472 $765,041
Commercial Insurance 198 $331,942 $265,553
Self/Private Pay 176 $295,059 $14,753
30% Medicare Co-Pay Collection 45,655
Total Estimated Payor Mix Reimbursement $1,675,886
Minus PP-GEMT Non-Federal Share Payments to the State $273,436 Total Estimated Payor Mix Reimbursement $1,402,451
NOTE: This valuation should be confirmed by the City’s billing contractor as payor mixes, reimbursements, and call volumes are constantly evolving and can have a significant impact on the cost recovery in the system.
AP Triton typically sees reimbursements that fall between 25–35% of the total billed amounts. This uses the realized collection percentages in selected departments and agencies across California.
Using this calculation, $3,688,240 would have been billed and $1,675,886 collected ($1,675,886 ÷ $3,688,240 = 45.44%).
This estimate is a cautious calculation of what may be collected based on the specified parameters.
Wittman LLC's real-world collections were 74% higher during the same period. This difference in collections versus prediction can be explained in various ways including conservative modeling compared to actual field performance, lump sum back payments received this year for previous year services, or other payments that are outside the normal reimbursement structure. The City should investigate the difference with Wittman before estimating future cost recovery based on past performance.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 33 AMBULANCE ENTERPRISE FUND
The report’s modeling section presents models for the ambulance enterprise fund, each featuring a component referred to as a “roll-over fund.” This mechanism introduces a 10%-line item to the financial models, designed to provide greater stability to the system. By including this additional allocation, the fund is better positioned to withstand various fluctuations that may occur in cost recovery, ensuring the financial health and sustainability of the ambulance services.
Purpose
An Enterprise Fund is a governmental accounting mechanism used to account for operations that are financed and operated in a manner similar to a private business. For a municipal ambulance transport program, an Enterprise Fund provides a dedicated financial structure that segregates ambulance service revenues and expenditures from the City's General Fund while ensuring transparency, accountability, and long-term financial sustainability.
The primary purpose of establishing an Ambulance Transport Enterprise Fund is to:
• Capture the full cost of providing ambulance transport services • Ensure ambulance-related revenues are used to support ambulance operations and capital needs
• Promote transparency in rate-setting and cost recovery • Support long-term planning for ambulance replacement, equipment purchases, and system expansion
• Demonstrate financial performance independent of General Fund operations • Facilitate participation in supplemental reimbursement programs, including California's Public Provider Ground Emergency Medical Transport (PP-GEMT) program Use
Under an Enterprise Fund structure, all revenues and expenditures associated with ambulance transport services are recorded within a dedicated fund. Typical revenues include:
• All Patient transport reimbursements from insurance carriers and patients • PP-GEMT supplemental reimbursements
• Interest earnings and other operating revenues
Typical expenditures include:
• Ambulance personnel salaries and benefits
• Ambulance operations and maintenance
• Medical supplies and pharmaceuticals
• Billing and collection services
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 34 • Vehicle replacement and fleet maintenance
• Facilities and administrative support costs
• Technology, communications, and dispatch-related expenses • Capital equipment purchases and debt service obligations The Enterprise Fund allows elected officials, management, and the public to clearly evaluate whether ambulance transport revenues are sufficient to support ongoing operations and future capital needs.
Establishment and Setup
Governing Body Action
The Calexico City Council should formally establish the Ambulance Transport Enterprise Fund through adoption of a resolution, ordinance, or budget action. The establishing action should identify:
• The purpose of the fund
• Authorized revenue sources
• Authorized expenditures
• Financial reporting requirements
• Reserve and capital funding objectives
Transfer of Ambulance Operations
All ambulance transport revenues and expenditures should be assigned to the Enterprise Fund.
Development of Financial Policies
The City should establish policies addressing:
• Cost recovery objectives
• Rate review frequency
• Reserve requirements
• Capital replacement funding
• Use of excess revenues
Establish Capital and Operating Reserves
Enterprise Funds should maintain adequate reserves to support operational stability and future capital needs. Recommended reserve categories may include:
• Operating Reserve
• Emergency Contingency Reserve
• Ambulance Replacement Reserve
• Equipment Replacement Reserve
• Capital Improvement Reserve
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 35 Establish User Fees and Rates
Transport rates should be reviewed at least annually to ensure compliance with applicable legal requirements and to maintain alignment with service costs, market conditions, reimbursement trends, and financial objectives.
Implement Financial Reporting and Performance Monitoring The Enterprise Fund should produce annual financial statements and monitor key performance indicators, including:
• Operating revenues and expenses
• Net operating income
• Cost recovery percentage
• Collection rates
• Ambulance utilization
• Reserve balances
• Capital replacement funding levels
Benefits
An Ambulance Transport Enterprise Fund provides several advantages to the City:
• Financial Transparency - Clearly demonstrates the costs and revenues associated with ambulance transport services.
• Sustainability - Supports long-term planning for ambulance replacement, staffing growth, equipment purchases, and facility needs.
• Reduced General Fund Reliance - Allows ambulance operations to be funded primarily through user fees, insurance reimbursements, and supplemental federal funding sources rather than ongoing General Fund subsidies.
• Improved Decision-Making - Provides City leadership with accurate financial information regarding service performance, cost recovery, and future funding requirements.
Revenue Sufficiency, Reserves, and Proposition 26 Compliance Although an Ambulance Transport Enterprise Fund utilizes business-type accounting principles, its purpose is not to generate profit in the traditional private-sector sense. Rather, the objective is to establish a financially sustainable funding structure that generates sufficient revenues to support the full cost of providing ambulance transport services, maintain appropriate reserve levels, fund capital replacement needs, and ensure the long-term viability of the system.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 36 In some years, Enterprise Fund revenues may exceed annual operating expenses. These excess revenues are not considered profit available for unrelated governmental purposes, but instead provide resources necessary to support ongoing ambulance system operations and future obligations. Fund balances may be used to support:
• Ambulance and fleet replacement
• Medical equipment replacement and technology upgrades • Facility improvements and operational infrastructure
• Operating and emergency contingency reserves
• Cash flow requirements resulting from reimbursement delays • Future service expansion and system enhancements
• Funding stability during economic downturns or reimbursement reductions Maintaining prudent reserves is particularly important for ambulance transport systems due to the significant capital investment required for ambulance replacement, the uncertainty of healthcare reimbursement rates, and the timing differences between service delivery and revenue collection.
Adequate reserves also help ensure continuity of service during periods of unexpected operational or financial stress. The report’s modeling section features a component referred to as a “roll-over fund.” This identifies a 10%-line item to the financial models to establish Operating reserves.
As a California public agency, the City of Calexico should establish and annually review ambulance transport rates and fees to ensure compliance with Proposition 26 and other applicable legal requirements. Proposition 26 generally requires that local government fees bear a reasonable relationship to the cost of providing the service and are not imposed for the primary purpose of generating unrestricted general governmental revenue. Accordingly, ambulance transport rates should be supported by periodic cost analyses and financial reviews demonstrating that revenues are reasonably related to the costs of providing ambulance transport services, maintaining prudent reserve levels, funding capital replacement needs, and supporting the long-term sustainability of the ambulance system.
Conclusion
Establishing an Ambulance Transport Enterprise Fund allows the City of Calexico to manage ambulance services as a financially self-supporting operation while maintaining accountability and transparency. By consolidating all ambulance-related revenues and expenditures into a dedicated fund, the City can better evaluate financial performance, support participation in the PP-GEMT program, fund future capital needs, maintain appropriate reserves, and ensure the long-term sustainability of ambulance transport services.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 37 RESOURCE NEEDS AND
WORKLOAD ASSESSMENT
UNIT HOUR UTILIZATION & TIME ON TASK
Unit Hour Utilization (UHU), workload, and time on task (TOT) are closely related measures that describe how busy resources are, but each captures a slightly different aspect of system performance.
UHU is the broadest metric and represents the proportion of time a unit is committed to calls compared to the total time it is available for service. It is typically expressed as a ratio or percentage and is used as a benchmark for system capacity and reliability. Workload builds on this by looking at the volume and distribution of calls placed on the system, often expressed as incidents per unit, per hour, or per population. Workload also includes non-incident-based activities like meal breaks, training, and sleep on a 24-hour shift. While UHU tells you how “busy” units are overall, workload helps explain why, by showing the demand being placed on the system.
Time on task is the most granular of the three and reflects the actual duration of individual responses, from dispatch to unit clear. It captures all components of a call, including response time, on-scene time, transport, and turnaround. Time on task directly drives both workload and UHU; longer call durations increase the total committed time, which raises UHU even if call volume remains constant.
Together, these metrics provide a complete picture: workload defines demand, time on task defines how long resources are tied up meeting that demand, and UHU reflects the cumulative impact on system availability. In combination, they are essential for determining whether a system is adequately resourced or operating at a level that risks delays in response and degraded service.
Unit hour utilization and workload are critical factors in structuring an EMS system. UHU measures how efficiently resources, such as personnel and equipment, are used to provide services. Other structural factors include response models (fire or private-based), support units, supervision, and surge protection, all of which must be considered as the system evolves.
Workload varies by industry and standard. For example, a nurse working a 12-hour hospital shift may remain consistently engaged but not overwhelmed, while a firefighter working a 24-hour shift with continuous calls would experience an unsustainable workload. Understanding how time is allocated during a standard shift helps in determining capacity for emergency call volume.
Assessing UHU at the field level is essential for building a system that meets the workforce's operational demands. Ensuring sufficient time for daily operations, such as equipment checks, training, and breaks, is crucial in transport system management. The private industry relies on status management to align unit availability with emergency demand, optimizing response times for critical and non-critical calls.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 38 A well-designed deployment model would allow Calexico Fire Department to maximize its resources and cost recovery without overburdening personnel. The figure below illustrates how UHU is developed. In this example, a 24-hour unit has 11-16 hours per day allocated for non-emergency activities, including equipment checks, breaks, training, and rest. This leaves 8-13 hours, or 35%-55% (0.35-0.55 UHU), available for emergency calls, providing a benchmark for sustainable workload management. Although this percentage of emergency response and other duties might fluctuate daily, the system should be built in a sustainable manner, understanding that every day might bring new challenges. UHU is about setting up a sustainable system, it is not about covering the call volume for one day. The following figure outlines an example of the workload breakdown for crews working either a 24- or 12-hour shift.
Figure 26: Determining Adequate UHU 24-hours/12-hours
Daily Operations Count Count
Hours in the day 24 Hours 12 Hours
Unit/Equipment Maintenance 1 1
Food Breaks 1-3 2
Fitness/Training 1-2 1
Sleep 6 0
Other 1-2 0
Wall Time (APOT) 1-2 1.5
Used Hours in Normal Day 11-16 5.5
Standing TOT 0.45-0.66 0.46
Maximum Recommended UHU 0.35-0.55 0.54
Standard UHU
Dual Role (firefighter ambulance) .35-.40 .35-.40
Single Role .45-.55 .50-.75
Specific data for each ambulance transport unit in CFD on medical aids is described in the service delivery section of this report. Using these numbers as well as the transport volume from data provided is a strong indicator of the impact on the system. These numbers can also help to understand the desired UHU in the system.
Using the 2025 medical call volume and a standard UHU of 0.45 or 45%, the number of ambulances needed in the system can be estimated and compared against the actual deployment of the current system.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 39 PROJECTED UNIT DEPLOYMENT
Projecting the number of units needed in the system takes into consideration many factors. UHU is a major factor along with call continuance (calls occurring at the same time or day) and timing of calls each day. A system that has a heavy call continuance at certain times of the day might indicate the need for additional 10- or 12-hour units to cover busy (surge) times while not needing those units at slower times. An example would be requiring a surge unit from 8 am-6 pm to cover peak activity and relying on 24-hour units from 10 pm-8 am due to the slowdown of calls overnight.
The figures below take into consideration call volume, transport volume, and non-transport volume.
This, along with call concurrence and call volume, helps to portray a complete picture. A six-step system is used to understand the estimated deployment needs:
• Step 1 – Suggested unit hours (call volume)
• Step 2 – Required unit hours (transport volume)
• Step 3 – Gap between call volume and transport volume • Step 4 – Call concurrence
• Step 5 – Current provider configuration
• Step 6 – Future planning
Steps #1-3 – Suggested Unit Hours
The first step is to calculate the number of units suggested based on the call volume, using the desired Unit Hour Utilization (UHU). Using the information provided by the Department and the figure above describing an adequate workload for firefighter and ambulance operator (AO) models, a UHU of 0.45 or 45% will be used for the study. If the City desires a higher or lower UHU, these assumptions will need to be adjusted. This UHU along with the projected call volume will give a suggested number of hours that should be deployed. This number is suggested because it covers the upper end of deployment, assuming a transport unit is sent to and used on each call in the system.
The second step is to use the same calculation for the total number of transports. Sixty minutes will be used as the time on task for each call. This will give the lower end of the estimated deployment.
The third step is determining the gap between the call volume and transport volume which means that some units will respond to calls and not perform a transport. This time on task is usually shorter than the evaluation and transport time. It is set at 20 minutes for this evaluation. Taking this non-transport volume into consideration will help to determine the need to estimate on the upper or lower side of transport units required and help determine the need for the addition of 12-hour units.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 40 Figure 27: UHU / Medical Aid Information
Call/Deployment Information EMS 5
Total Medical Aids 3,887
Total Transports 2,202
UHU 0.45
Deployment Hours Required 4,893 - 8,638
Total Daily Hours Required 13.41 – 23.67
Estimated 24-Hour Units Required (Step #1 / Step #2) 1.0 - 2.0 Total non-transports 1,685
UHU 0.54
Deployment Hours Required 1,040
Total Daily Hours Required 2.85
12-Hour Units Required (Step #3) 1.0
Total Medical Aids – Determined through information provided Total Transports – Determined through information provided UHU – Determined using the information provided and industry standards Deployment Hour Required – Total Medical Aids x 1 hour (average length of call) / UHU Total Daily Hour Required – Deployment Hours Required / 365 days 24-Hour Units Required – Total Daily Required Units / 24 hours (rounding up) Step #4 – Call Concurrence
The three steps above show the range needed for 24-hour units with the possibility of 12-hour surge units. For the fourth step, this estimated number of units is then evaluated against the more specific daily/hourly call/transport volume figure below to determine how the call concurrence could affect unit availability.
The figure below takes into consideration the call volume, hours of the day, days of the week, and the desired UHU to estimate the number of ambulance transport units required in Calexico.
Staffing the system with non-firefighters has unique challenges in a system that typically has sworn personnel on 24-hour shifts. If Calexico chooses a model that involves firefighter staffing, unit configuration could be adjusted to staff more 24-hour units and the units that are staffed at 12 hours could be done with overtime instead of full-time employees.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 41 There were 3,887 medical aid incidents and 2,202 transports in 2025. To cover this amount of transport using the 0.45 UHU, it requires 4,893 - 8,916 deployment hours. This number of hours indicates the need for one to two 24-hour units. The charts below show the call volume per day/hour for 2025, indicating a higher volume from 9 am – 5 pm, indicating a need for up to two units. The use of surge units from 9 am to 5 pm could be used to cover the call volume during these higher call volume times, while allowing the normal staffing to cover the slower night and morning periods. The following figure shows the need for 1-2 units during non-peak hours.
Figure 28: UHU / Unit Coverage
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 42 Figure 29: Estimated Unit Needs per Call Volume
The call volume and unit needs indicate the need for two full-time units or a combination of one fulltime unit and one to two surge units for peak time periods. These surge units can be covered in separate ways based on the type of employee. A single-role (ambulance operator) model could fill the position with full-time employees, overtime, or with a robust part-time group that could cover open shifts. A dual-role (firefighter) model would typically fill this role with full-time personnel working overtime. To ensure the modeling is consistent, all models will be staffed using overtime personnel to fill any 12-hour surge units. Although the call volume in Calexico indicates the need for a surge unit for coverage during peak hours, the transport volume indicates only two full-time units are needed.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 43 Step #5 – Current Configuration
Steps one through four use data and metrics to determine system needs, while steps five and six factors in current and future contexts. It is important, in step 5, to consider current ambulance setup, EMS standards, and response times so that practical factors are not ignored in favor of data alone.
Information received during this study estimates the current ambulance configuration for Calexico is two to three ambulance transport units depending on staffing with a combination of ALS and BLS configurations also depending on staffing. This configuration is estimated at 17,520-26,280 Unit Hours per year, and consistent with the proposed model.
• Two ambulance transport units x 8,760 hours (24 hours x 365 days) = 17,520 hours Step #6 – Future Planning
Step 6 deals with future planning and is completed after the system is running. As the system is built out, a clear understanding of the current needs, including adding to or reducing from the initial unit deployment model. Once the deployment is stable, future call volume will dictate the changes in unit hours. It is crucial for the City to monitor the call volume in the system and adjust the unit hours to maintain appropriate response times and ambulance unit hour utilization. Staffing needs will also become clearer if a single-role model is deployed.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 44 COSTS OF THE EMS SYSTEM
Analyzing the costs associated with field service delivery includes multiple expenses. All ambulance transport delivery models offer diverse benefits and challenges. The main cost items that will be discussed in this section are salaries, benefits, and potential overtime costs to give a comprehensive understanding of the potential personnel costs for different ambulance transport models. Other items that will be discussed in this section are administrative costs, overhead costs, and additional start-up costs.
PERSONNEL COSTS
Analyzing costs associated with field service delivery is important to understanding the entire system.
Multiple items under personnel will be considered when developing the system's modeling including salary, benefits, overtime, and other related expenses. Typically, the two main cost items (salary and benefits) are known factors that each city/county or human resources department provides and make up the primary costs when deploying units.
Annual budgeted personnel costs were provided for this report. Positions were identified by the Department with minimum and maximum salary ranges. Through analysis of the ranges, the maximum annual salaries were utilized as average salaries were noted to be significantly closer to the maximums. Personnel costs provided for this study are included in the following figure.
Figure 30: 2025 Employee Salaries
Position Minimum Maximum
Straight
Hourly
Cost
Total
Salaries &
Benefits
Total
Hourly
Cost
Fire Chief $114,495 $139,169 $66.91 $244,724 $117.76
Inspector $73,567 $93,947 $45.17 $182,059 $87.53
Captain $73,566 $91,948 $31.58 $173,582 $59.61
Engineer $60,452 $77,107 $26.48 $159,098 $54.63
FF/Paramedic $57,081 $72,851 $25.02 $139,282 $47.83
Administrative Assistant $39,764 $48,333 $23.24 $93,835 $45.11 EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 45 Minimum staffing for daily CFD deployment includes two engine companies and two ambulance transport units. Engine companies are staffed at minimum with one captain, one engineer, and one firefighter paramedic. Ambulance transport units are staffed with two firefighter paramedics. At any given shift, additional personnel may augment staffing of response units. Additionally, personnel filling minimum staffing positions may be in an assigned role due to overtime or shift trade opportunities outside their normal job classification ranking. For standardization of this report, minimum staffing levels will be used to model costing. In addition, positions outside of direct operational response staffing are not included in the cost modeling analysis, despite their critical role in the overall management, administration, and daily support functions of the Calexico Fire Department.
Administrative and support positions are considered fixed or baseline costs that generally remain consistent regardless of changes to frontline operational staffing configurations.
The current CFD shift schedule consists of a two-days-on/four-days-off rotation and maintains a minimum daily staffing level of two captains, two engineers, and five firefighter/paramedics per shift.
Under this staffing model, each position is scheduled for 1,248 straight-time hours annually.
Figure 31: Current Daily and Annual Staffing Cost (no overtime) Position Hourly Rate Daily Shift Cost Annual Staffing Cost Captain (2) $59.61 $2,861 $1,044,265
Engineer (2) $54.63 $2,622 $957,030
FF/Paramedic (5) $47.83 $5,740 $2,094,100
Total Staffing Cost $11,223 $4,096,395
The current CFD annual minimum shift staffing calculated cost is over $4,096,395. Current approved budgeted operational staffing is 5 captains, 5 engineers, and 15 firefighter paramedics. This would require that overtime be utilized to meet minimum daily staffing requirements just to meet the threeplatoon minimum shift staffing. Where this could reduce non-salary cost (benefits), it adds to hourly base cost (time and one-half), fatigue, and burnout. Additional overtime would be needed to cover sick leave, vacation, and FMLA events.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 46 SALARY
The salaries for personnel in the models described in this report are divided into two distinct categories: sworn and non-sworn.
Non-Sworn
If the city chooses to fill the single role ambulance operator (non-sworn) positions with established CFD dual-role employees (sworn), it is important to understand the salary structure. The structure can be more versatile than the set 24-hour schedule that firefighters typically work.
There are three basic methods for staffing a 24-hour coverage system: 24-hour shifts, A/B 12-hour shifts, and 12-hour shifts. Non-sworn personnel are typically considered “non-exempt” from the Fair Labor and Standards Act (FSLA), which means they will get overtime for any hours worked over 40 in a week, so each model explored accounts for overtime built into the schedule.3 • The 24-hour model requires six personnel and is like the firefighter model. It will typically be staffed with full-time employees with part-time employees covering open or extra shifts. • The A/B 12-hour shift covers the same 24-hour period with two shifts. This requires eight personnel to cover the full deployment of one ambulance. These positions can be staffed with fulltime employees, part-time employees, or a combination of both. • Using a 12-hour shift will typically be used to cover surge periods in a day or week and can be filled with full-time or part-time employees.
The figure below gives an example of a comparison between a (1) 24-hour shift and (2) 12-hour shifts covering a 24-hour period to help understand the costs related to each deployment. This is an example using proposed ambulance hourly costs and a basic life support unit. 3 https://www.dol.gov/agencies/whd/compliance-assistance/handy-reference-guide-flsa?utm.com.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 47 Figure 32: 24-Hour / 12-Hour Shifts
24/12 hour Straight/OT Hourly Rate Number of
Hours
# of
Personnel Yearly Cost
24-Hour Shift – 6 Personnel Required to Staff
24-hour Straight Time $19.00 2,016 1 EMT $38,304
Overtime $28.50 824 1 EMT $23,484
Total Salary for One EMT $61,788
Total Benefit Package for One EMT (55% of Salary) $33,983 One 24-hour shift EMT (Salary + Benefits) $95,771
Total Salary and Benefits for One 24-hour Shift Ambulance (6 Personnel) $574,626 12-Hour (A-B) Shift – 8 Personnel Required to Staff
12-hour Straight Time $19.00 1,928 1 EMT $36,632
Overtime $24.50 208 1 EMT $5,096
Total Salary for One EMT $41,728
Total Benefit Package for One EMT (55% of Salary) $22,950 Two 12-hour shifts require eight personnel $64,678
Total Salary and Benefits for Two 12-hour Shift Ambulances (8 Personnel) $517,427 Listing all the combinations of staffing possibilities would be extremely complicated and not an equal comparison of the models. To minimize confusion, the 24-hour shift will be used for all firefighter/AO staffing, but in the AO model the 24-hour shift will be filled with two 12-hour units. This option allows consistency in the design and a comparison of the models, while optimizing the shift flexibility of the ambulance operator position. Real-world logistics might require the City to pivot in the future, and understanding the staffing requirements of each model will be important in the success of the overall program. Model 4 will discuss the use of different hourly staffing models and how they would affect the overall system.
This schedule is one way to staff and pay employees. There are other options that could be explored if the city chooses a non-sworn model. The average annual income using this model is listed below. • Non-Sworn EMT - $42,560
• Non-Sworn Paramedic - $54,880
Sworn
Sworn salaries are based on the Calexico Fire Department’s salaries. Typically, there is a 12-18% bonus added to the Firefighter EMT salary for maintaining a paramedic license. The salaries are based on a 56-hour work week and 2,912 hours per year.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 48 • EMT Firefighter Salary - $62,956
• PM Firefighter Salary - $68,060
BENEFITS
The benefit package can vary for sworn and non-sworn employees. It usually includes medical, dental, life insurance, HR overhead, various PERS or other retirement formulas, short, and long-term disability, leave, and other costs, depending on the provider. A typical benefits package can range in percentages of the base pay from 50% - 60% for most systems. A benefits package using 55% of the Ambulance Operators base pay for all ambulance positions will be used (non-sworn). The actual benefits package for firefighters will be used.
• Non-Sworn Yearly Benefits Package - $23,408 - $30,184 • Sworn Yearly Benefits Package - $65,880 - $71,222
Overtime
Overtime requirements can vary significantly depending on the classification of personnel evaluated, such as sworn versus non-sworn employees, as well as the amount and structure of leave benefits provided by the City. Paid leave benefits may be funded through different mechanisms depending on agency staffing policies, with some leave costs absorbed directly within departmental operating budgets and others allocated through employee benefit programs.
For purposes of this staffing and cost modeling analysis, an assumption of 192 hours annually (equivalent to eight 24-hour shifts) of paid time off (PTO) will be applied for non-sworn 24-hour personnel within each model. In comparison, total annual leave utilization for firefighter staffing models is estimated to average approximately 276 hours per employee per year.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 49 The figure below covers the costs of overtime to cover 192 hours in a non-sworn position.
Figure 33: Overtime Pay Calculation
24/12 hour Full/A-B
Shift
Overtime
Hourly Rate
Straight Time
Hours
# of
Personnel Yearly Cost
24-Hour Shift – 6 Personnel Required to Staff (Non-Sworn) 24-hour Full Shift $28.50 192 hours 1 EMT $5,472
24-hour Full Shift $36.75 192 hours 1 PM $7,056
Total Overtime Costs for One 24-hour Shift Ambulance (6 Personnel) $37,584 24-Hour Shift – 6 Personnel Required to Staff (Sworn)
24-hour Full Shift $32.43 276 hours 1 EMT $8,950
24-hour Full Shift $35.06 276 hours 1 PM $9,677
Total Overtime Costs for One 24-hour Shift Ambulance $55,881
PERSONNEL COSTS
This section covers administrative overhead costs for the ambulance transport system, taking into consideration the size and scope of CFD. These positions may be adjusted based on the needs of the city.
Director / Deputy Chief EMS
AP Triton typically recommends a Senior Manager or Director position responsible for the complete oversight and planning of a system, depending on the size and scope of the deployment. In the fire service this is typically an Assistant/Deputy Chief position. The duties described above will be managed by the existing Fire Chief. This position will be responsible for millions of dollars in revenues and expenditure.
Manager / Captain Logistics Coordinator EMS
The level of overhead and administrative staffing required will vary depending on the service delivery model ultimately selected by the Calexico Fire Department. If a single-role model is adopted, there will be an increased need for hiring, training, and education as personnel turnover will increase. Each configuration also considers daily supervision. AP Triton’s algorithm typically requires at least one supervisor in the field per six ambulances in service. This number can fluctuate based on the suppression provided from existing fire units in the field and the diverse area of coverage. This position can also be covered by existing personnel that are filling dual roles, such as a floor captain managing the day-to-day operations of the program.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 50 Billing Oversight—Staff Analyst
This position provides oversight and coordination of ambulance billing operations between the City and the contracted billing provider. Responsibilities include ensuring electronic patient care report (ePCR) data is accurately transmitted to the billing contractor in a timely manner and monitoring billing and collection activities to identify trends, discrepancies, or operational issues that may impact revenue recovery.
This position is also responsible for tracking unit-hour utilization, preparing monthly operational and financial reports, and reconciling billing data with the billing contractor to ensure accuracy and consistency. In addition, the position monitors EMS enterprise funds to ensure revenues and expenditures remain compliant with operational requirements and approved budget parameters. The position also coordinates and administers compassionate billing or hardship assistance programs for patients who are unable to pay for services.
Additional Personnel
Calexico Fire Department is well-positioned to assume the roles listed above, and additionally offering on-site supervision during emergencies and at fire stations. This structure allows for seamless integration of ambulance operations while fulfilling daily supervisory requirements with minimal additional overhead.
The following figure lists the overhead position including salary and benefits provided to AP Triton for this study. Additional information will be required once a model is chosen to create an accurate picture of potential administrative costs.
Figure 34: Administrative Overhead Positions
Position # of
Personnel Salaries/Benefits/Overtime Total
Billing Staff Analyst 1 $93,835 $93,835
OVERHEAD COSTS
Overhead costs can vary between systems but typically account for approximately 20% of the total system cost when compared to other fire departments providing similar services. These expenses extend beyond direct patient care and operational costs, encompassing various administrative and support functions.
Below is a list of some expected overhead costs. Some of these items are included in the current modeling, while others are not. Calexico City should carefully evaluate all potential and current expenses before selecting a sustainable model for the future, including housing costs. Housing of personnel is a tricky thing to estimate when comparing models. If the fire department participates in EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 51 the management, it is assumed that personnel will be housed in the fire stations. If non-sworn personnel are to be housed outside the fire station, additional costs should be estimated. Conversely, non-sworn personnel working 12-hour shifts often do not have housing costs as they continuously are relocating to meet system demands. For the purposes of this report, additional housing costs are not included in any of the models.
Administrative Expenses
Administrative expenses include other things that are often overlooked, such as office rent and utilities, office supplies, salaries for additional administrative staff, training and education costs, licensing and certifications, dispatch and communications equipment, quality assurance and compliance, medical, marketing and community outreach, and legal and professional fees. These additional expenses should be explored as the City considers updating their delivery model. Other costs such as insurance premiums, vehicle depreciation and replacement, supplies and equipment inventory have line items in the modeling section below.
Billing Costs in the Ambulance Transport System
Within an ambulance transport system, billing is composed of key components. These include a base rate for the transport, a mileage charge based on the distance traveled, and adjustments depending on the level of service provided, such as basic life support (BLS) or advanced life support (ALS). Additional charges may apply for supplies, medications, and advanced treatments administered during transport.
The overall billing process is further complicated by administrative and overhead costs associated with claim submission, ongoing follow-up, and collections activities.
Fixed and Variable Cost Considerations
When evaluating the financial structure of ambulance billing, it is essential to distinguish between fixed and variable costs. Administrative and billing expenses tend to be scaled in proportion to the volume and complexity of transport, while costs such as mileage and service level increase with both distance and the acuity of patient needs. Other influential factors include the payor mix, such as insured versus uninsured patients or in-network versus out-of-network claims, regulatory rate schedules, and the risk of uncollected revenue due to unmanageable debt or uninsured patients. These elements collectively shape the net revenue and long-term sustainability of the system. Calexico’s financial structure should not change if the City decides to update its delivery model, but all future deployment models should be discussed with the City’s ambulance billing provider to ensure accuracy.
Typical Billing Costs and Outsourcing Benefits
Billing costs typically fall within a 3% to 5% range of net collections. Utilizing an external billing company can be advantageous. Such companies often have specialized expertise in regulatory compliance, claim processing, and appeals, which can result in more effective collections and reduce administrative challenges for the agency. Calexico is currently utilizing Wittman Enterprises, LLC for their billing and collections and is charged 4.75% of net collections. There is also a $15.00 per nontransport charged by Wittman per the contract.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 52 Cost Recovery Example
The following figure illustrates projected billing costs under varying collection percentage scenarios based on anticipated cost-recovery revenue. This analysis provides a practical framework for future budgeting, financial forecasting, and long-term planning within the ambulance transport system. These projections do not include the $15 per non-transport charge.
Figure 35: Estimated Billing Percentage and Net Cost Recovery Percentage of Billing Projected Net Cost Recovery Projected Annual Fees
3.50% $1,675,000 – 2,922,000 $58,625 – $102,270
4.00% $1,675,000 – 2,922,000 $67,000 - $116,880
4.25% $1,675,000 – 2,922,000 $71,188 - $124,185
4.50% $1,675,000 – 2,922,000 $75,375 - $131,490
4.75% $1,675,000 – 2,922,000 $79,563 – $138,795
5.00% $1,675,000 – 2,922,000 $83,750 - $146,100
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 53 COST RECOVERY
ANALYSIS OF POTENTIAL REVENUE STREAMS
Financial Resources
Cost recovery in an EMS and ambulance transport system is straightforward, with well-established expenses for service delivery, particularly in fire department-operated models. Many fire departments have provided these services for decades, with structured financial models in place.
Programs such as First Responder initiatives and the Federal PP-GEMT program have enabled public agencies in California and other states to recoup a portion of the costs associated with Pre-Hospital Emergency Medical Services (PHEMS). These funding mechanisms help offset operational expenses and enhance system sustainability.
Funding
Funding for an emergency transport system is primarily dependent on patient transportation, as outlined in this report and the payor mix section. This funding is supported through three key mechanisms:
Transport Fees – Charges billed to patients or insurers for ambulance transport services.
Federal Reimbursement – Funding received from programs such as Medicare, Medicaid, and other federal initiatives.
Additional Taxes or Fees – Supplemental funding sources, including local taxes or special assessments, to support system sustainability.
A balanced approach incorporating these mechanisms ensures financial stability while maintaining essential emergency medical services.
Transport Fees
If Calexico Fire Department chooses to update its EMS transport and billing system, it should also ensure its own fee structure meets the needs of the system. AP Triton recommends that the provider of record establish transport and related service fees at levels that promote long-term financial sustainability while remaining reasonable, defensible, and consistent with community and regional market considerations.
Understanding the payor mix is crucial in assessing how the fee structure impacts cost recovery. A well-balanced fee model should align with reimbursement rates and funding mechanisms to support the long-term viability of the EMS system.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 54 Federal Reimbursement
Multiple Federal programs offer additional reimbursement for ambulance transport and, sometimes, non-transport. All public and private agencies must optimize their cost recovery in the system by participating in provided programs.
Additional Fees and Taxes
Charging the patient for the PHEMS response to all calls is vital to establishing a sustainable system.
Setting up additional fees is not part of this EMS valuation study but is already part of CFD’s cost recovery strategy and is outlined in this report.
Collection Rates
The collection rate is important, but the quality of the collections is more important. Any system can guarantee a 90%-100% collection rate if the service fee is low enough. Consider the cost of transport at $500.00 and the total amount of transports at 5,000 per year. At this rate, Calexico would collect 100% of what is being charged, but even at a 90% collection, it would put the total charge at $2,500,000 and the estimated cost recovery at $2,250,000. Using the same number of transports, a fee for transport of $2,000, and a 40% collection rate, the cost recovery jumps to an estimated yearly $4,000,000. Not only has the cost recovery in the system almost doubled, but the impact on the residents is minimal, as this increase in fees leverages the reimbursement from commercial insurance providers.
As stated previously, a 25%-35% collection rate is typical for an ambulance transport system. If the collection rate is lower, the fees are typically considered too high; if the collection rate is higher, the fee is typically too low. Many more factors are involved in the collection rate, including the specific payors involved. As the provider of records, it is recommended for CFD to establish a fee structure that allows them to collect, at minimum, 25%-35% of what is billed.
FEDERAL REIMBURSEMENT PROGRAMS
Public Provider Ground Emergency Medical Transport (PP-GEMT) Reimbursement for patient transport to the hospital is based on the four payor mixes previously outlined in this study. In California, Medi-Cal provides additional avenues to recover costs beyond the initial billing phase.
Reimbursement Programs
Two major Federal programs currently offer additional reimbursement for the treatment and transportation of Medi-Cal patients in California:
• IGT (Intergovernmental Transfer)
• PP-GEMT – (Public Provider Ground Emergency Medical Transportation) EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 55 IGT
The IGT method for a public agency to demonstrate monetary loss is through an Intergovernmental Transfer (IGT) program. To participate, the City contributes funds to the State, which then leverages these funds to draw matching federal funds.
Throughout this process, administrative fees are deducted at various stages, with different entities taking a portion for managing the program. Once the transfer and management are complete, the Provider of Record receives the additional funds, helping to offset operational losses.
PP-GEMT
Figure 36: PP-GEMT Program Steps and Cycle
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 56 Until January of 2023, most public agencies participated in the GEMT and Quality Assurance Fund (QAF) programs to enhance the cost recovery from Medi-Cal patients. In 2016, the initial designers of the GEMT program went to the State and attempted to clarify the terms of the program so that a fire department could include EMTs and other first responders on medical aid calls in the Certified Cost Reports (CPEs). After years of lobbying, AB1705 was adopted, which took Public Providers (PP) out of the GEMT and QAF programs and put them in a separate program called the Public Provider Ground Emergency Medical Transport (PP-GEMT)4
. The new program is a hybrid IGT. The previous CPE reports from all the agencies in the state were used to produce an enhanced fee paid to each agency based on the number of Medicaid patients they transported. The enhancement was $1,065, compared to the previous $339. The program requires a quarterly payment like the QAF, about $330 per Medi-Cal transport, and they also take an additional 10% for program management and $30 per Medi-Cal patient transported to account for non-paying entities. These numbers have increased over the last year with a reimbursement of $1,158.10 and a required payment of $349 and are set to increase again in 2026.
Sustainability of the Program
One aspect of the new program is that all Public Providers receive enhanced reimbursement on their billing of Medi-Cal patients, sometimes increasing their cost recovery by millions per year. Although the program mandates all agencies receive the enhancement, it does not require the quarterly payments. However, because the program is specifically structured to avoid any financial impact to the State’s General Fund, continued participation depends on local agencies consistently contributing their required share of funding. Failure by participating agencies to meet those obligations could jeopardize or ultimately result in the dissolution of the program. If Calexico continues with a model that allows for transportation billing, the sustainability of the PP-GEMT program will be vital for enhanced cost recovery for the City.
As noted, the PP-GEMT program is the current program in place for public agencies and has significantly increased the system's cost recovery. Below is an estimation of the PP-GEMT enhancement that Calexico could see if they maintain their status of provider of record for the transportation system. The following figure compares the difference between a private provider and a public provider in the system.
4 https://www.dhcs.ca.gov/provgovpart/Pages/PPGEMTIGT.aspx.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 57 Figure 37: PP-GEMT Cost/Cost Recovery Estimations 2026 Provider
Projected
Medi-Cal
Transports
Normal
Federal
Reimbursement
Potential
Enhancement
Estimated
IGT
Estimated
Fee
NonPayor
Fee
Cost
Recovery
Public 1,166 $118.00 $1,158.00 $349.02 $34.90 $30.00 $867,788* Private 1,166 $118.00 $339.00 $34.00 10% N/A $249,934** *Calculated using only the number of Medi-Cal patients
**Calculated using all patients transported
Because the City is not currently making its required quarterly payments into the program, other participating agencies are effectively covering Calexico’s share in order to maintain continued operation of the system. While this may result in an estimated short-term savings of approximately $273,000 annually for the City, it also places the PP-GEMT program at risk and could jeopardize nearly $700,000 in annual supplemental reimbursement revenue currently available to the city through the program.
FIRST RESPONDER FEE
Charging fees for certain fire department services that are not funded through general tax revenues is a long-standing practice within the fire service. Fire departments commonly recover costs for services such as plan reviews for new or remodeled buildings, fire protection system reviews, and related inspections. These fees are intended to offset the costs associated with providing specialized services that fall beyond the traditional tax-supported responsibilities of fire protection.
However, charging fees associated with Pre-Hospital Emergency Medical Services (PHEMS) response is less universally implemented, even though emergency medical calls now represent a substantial portion of fire department responses in most California communities. Traditionally, municipal fire service funding has been derived from local tax revenues intended to support fire prevention, suppression, and mitigation of hazards that threaten the community. Emergency medical response, while now a routine function of the fire service, was not originally contemplated as part of this traditional funding model.
Fire stations located throughout a community provide a strategically distributed network of trained emergency responders capable of responding rapidly to a wide variety of emergencies. Firefighters trained at the BLS or ALS level have become a foundational component of modern emergency medical services systems across the United States. Their geographic distribution and rapid response capability make them particularly effective as first responders to medical emergencies.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 58 In Calexico, emergency medical services are delivered through a system that includes fire-based first responders and ambulance transport services. Firefighters trained as EMTs or paramedics respond to medical emergencies throughout the community, providing immediate patient assessment and stabilization. When patient transport is required, Calexico transports patients to the appropriate medical facility.
COST OF READINESS AND SYSTEM EFFICIENCY
Providing emergency medical response requires significant ongoing investment in personnel, facilities, equipment, training, and dispatch capabilities. This ongoing operational requirement is commonly referred to as the “cost of readiness.” The cost of maintaining personnel and equipment ready to respond at any moment represents the largest component of EMS system expenses.
Because of these readiness costs, relying solely on ambulances to deliver all components of emergency medical response is not cost-effective. Instead, communities like Calexico utilize a blended EMS system that incorporates fire-based first response units and ambulances. In this model, fire units typically arrive first due to their distribution throughout the community, allowing medical care to begin immediately while ambulance transport units continue to the scene.
This system improves response times, increases system efficiency, and allows fire resources to return to service quickly once patient care is transferred to the ambulance crew. The model also allows ambulance transport units to focus on patient transport while fire personnel provide rapid medical intervention during the critical initial stages of an emergency.
Although fire-based first response services are often provided without direct reimbursement, they represent a critical component of the overall EMS system and significantly contribute to improved patient outcomes.
LEGAL AND POLICY CONSIDERATIONS
The Warren 9-1-1 Emergency Assistance Act (AB 424)5 established a statewide emergency telephone system allowing individuals to request police, fire, or rescue services by dialing 9-1-1. As a result, both police officers and firefighters are trained in basic lifesaving techniques such as cardiopulmonary resuscitation (CPR). However, the legislation does not specifically mandate ambulance transport services or require fire agencies to provide advanced medical services. 5 California Government Code §§ 53100–53120, Warren-911 Emergency Assistance Act.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 59 Despite this, decades of research have demonstrated that rapid medical intervention significantly improves survival rates and reduces long-term disability in many emergency medical conditions.
Prompt treatment provided by trained first responders has been shown to improve outcomes in conditions such as cardiac arrest, trauma, stroke, and respiratory emergencies (National Highway Traffic Safety Administration, 19966
; American Heart Association, 20207). As a result, fire departments across the nation have increasingly assumed a leading role in emergency medical response.
While tax revenues support the core mission of fire protection, most EMS incidents involve medical conditions affecting individual patients rather than community-wide hazards. As EMS call volumes increase, these responses place additional demand on fire department resources funded by the general taxpayer.
Although discontinuing EMS response by fire departments would be neither practical nor beneficial to public safety, jurisdictions have adopted cost recovery programs to offset expenses associated with these services. State and federal regulations allow governmental agencies to recover costs associated with providing emergency medical services if fees are designed to recover expenses rather than generate profit.
COST RECOVERY METHODOLOGY
Cost recovery programs for EMS typically account for both direct costs and indirect costs associated with providing emergency medical response.
Direct costs include:
• Fire personnel providing emergency medical care
• Dispatch and communications services
• Fire apparatus and medical equipment
• Medical supplies and pharmaceuticals
Indirect costs typically include:
• Administrative oversight and supervision
• Training and continuing education
• Equipment maintenance and replacement
• Finance, human resources, and other support services
6 National Highway Traffic Safety Administration (NHTSA). (1996). EMS Agenda for the Future. 7 American Heart Association. 2025. 2025 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Systems of Care section (Chain of Survival discussion).
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 60 Calculating these costs allows a jurisdiction to establish a reasonable fee structure that supports the EMS system while remaining compliant with state and federal guidelines.
Many communities implement a First Response Fee (FRF) as part of their EMS cost recovery strategy.
These fees are applied when fire department personnel respond to medical emergencies and provide patient care prior to ambulance transport. The fee structure is typically calculated based on the cost of providing EMS services and the average annual call volume, while accounting for the likelihood that some patients will not have insurance or may otherwise be unable to pay.
The figure below represents an example of what the addition of a FRF could bring to the City. When evaluating a department’s fees for service, the goal should be to achieve 100% cost recovery or cost neutrality for the taxpayer's benefit. In doing this, the Department is placed in a stronger financial position than providing a service that requires subsidy from the general fund. FRF amounts referenced in this report are provided for informational and comparative purposes only and should not be interpreted as formal fee recommendations or adopted rates. Authorized under California Health and Safety Code Section 13916, Fire Responder Fees generally range from approximately $300 to $500 per patient among California EMS providers, depending on agency cost structures, service levels, and local policies.
Figure 38: Potential First Responder Fee & Cost Recovery Fee Estimated # of
Patients
Estimated
Commercial
Insurance
Estimated
Private Pay
Total Estimated
Reimbursement
Current Estimated
Reimbursement w/ NO
First Responder Fee
2,200 $265,553 $14,753 $280,306
Current Estimated
Reimbursement with
$100 First Responder Fee
2,200 $281,408 $15,634 $297,042
Current Estimated
Reimbursement with
$250 First Responder Fee
2,200 $305,189 $16,955 $322,144
Current Estimated
Reimbursement with
$500 First Responder Fee
2,200 $344,825 $19,157 $363,982
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 61 Section III:
EMS System Delivery
Modeling
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 62 DEPLOYMENT MODELING
AP Triton has evaluated multiple EMS delivery models and presents four options for Calexico Fire Department’s consideration. While the City may not fully implement each of these models, this assessment provides decision-makers with a clear understanding of the estimated costs associated with each approach. The goal is to help Calexico determine the most effective EMS service delivery and governance model to ensure high service levels for residents, businesses, and visitors.
EMS Service Models for Consideration:
• In-house service with sworn fire personnel
• In-house service with non-sworn fire personnel
• Hybrid model with sworn and non-sworn fire personnel
• Changes to ambulance staffing hours
These ambulance transport models incorporate Calexico’s known costs (where available) and industry standards from fire and private ambulance transport systems. While these cost estimates are based on real-world data, certain expenses, such as cardiac monitors, radios, gurney systems, and overtime, may vary. Non-sworn salaries align with industry standards but could be adjusted based on implementation decisions.
Comparing Cost Structures
Each model uses a standardized cost structure where applicable, allowing for direct comparisons between systems. The City must validate each expense outlined in this study before moving forward.
Legal Considerations
These models do not address CFD’s legal ability to continue or establish an alternate delivery model to their ambulance transport system. Before selecting a model, a thorough legal review under the EMS Act must be conducted.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 63 COMPARATIVE ANALYSIS OF DELIVERY MODELS
Model One: Firefighter Transport Model
Fire Agency Providing Ambulance Transport with Sworn Personnel Model One proposes a sworn firefighter/paramedic and sworn firefighter/EMT staffing model for delivering all emergency ambulance services in Calexico City. This is like the system in place.
Firefighters typically do not work 12-hour shifts, so this model relies on 24-hour ALS units rather than on split shifts. To maintain system consistency, total unit hours remain the same across all models. • Two 24-hour staffed ALS units are recommended.
Staffing & Cost Overview
The following figure outlines staffing and employee costs for Model One, including the 6 Firefighter/Paramedics and 6 Firefighter/EMTs.
Figure 39: Model One Firefighter Staffing Costs
Type of Personnel # of
Personnel Individual Total Estimated Annual Cost
Firefighter EMT Salary 6 $62,956 $377,736
Firefighter EMT Benefits 6 $65,880 $395,280
Constant Staffing – Overtime FF/EMTs* 6 276 PL Hours $53,703 Firefighter Paramedic Salary 6 $68,060 $408,360
Firefighter Paramedic Benefits 6 $71,222 $427,332
Constant Staffing – Overtime FF/PMs* 6 276 PL Hours $58,057 Estimated Staffing Cost $1,720,468
*Paid leave (PL)
Benefits/Challenges – Model One
In previous years, using sworn personnel for ambulance services was financially unfeasible. However, rising private provider costs per unit hour have made this model more viable.
Key Benefits
• Increased Staffing: Maintaining 12 sworn personnel could maintain emergency response flexibility within the fire service.
• Workforce Stability: While the initial onboarding academies would take longer than other models, the result would be a more consistent and trained workforce.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 64 Challenges and Considerations
• Hiring Constraints: Recruiting large numbers of sworn personnel could delay meeting service demands.
• Overtime Costs: All vacancies (e.g., sick leave, vacation) and flex car deployments would require sworn personnel working overtime, increasing expenses.
Model Two: Ambulance Operator Model
Fire Agencies Providing Ambulance Transport Non-Sworn Personnel Model Two employs non-sworn (Single-Role) personnel, with EMTs and paramedics staffing all ambulances. This model has gained popularity among fire departments transitioning into emergency transport services due to its flexibility and efficiency. To meet 337 weekly unit hours, the system requires:
• 8 EMTs and 8 paramedics working a combination of 24-hour and 12-hour shifts. • Robust Part-Time Workforce: Due to high turnover, maintaining a strong pool of part-time employees is essential.
Figure 40: Model Two Ambulance Operator (AO) Staffing Costs Type of Personnel # of
Personnel Individual Total Annual Cost
AO EMT Salaries (12-hours) 8 $42,560 $340,480
AO EMT Benefits 8 $23,408 $187,264
AO EMT Constant Staffing OT 8 192 PL Hours $43,776
AO PM Salaries (12-hours) 8 $54,880 $439,040
AO PM Benefits 8 $30,184 $241,472
AO PM Constant Staffing OT 8 192 PL Hours $56,448
Estimated Staffing Cost $1,308,480
Benefits/Challenges – Model Two
Key Benefits
• Flexible Staffing: Utilizes 24-hour units and 12-hour shifts, optimizing efficiency compared to sworn models.
• Firefighter Recruitment Pipeline: Acts as a training and vetting system for future full-time firefighters, as seen in multiple California fire departments.
Challenges and Considerations
• High Turnover Rates: Single-role EMS personnel typically experience frequent turnover, necessitating continuous hiring and training efforts.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 65 • Human Resources and Training Demands: Managing an ongoing recruitment and training cycle for part-time employees requires dedicated resources. • Part-Time Workforce Management: While part-time personnel help cover shifts and meet surge demand, maintaining consistent staffing levels can be challenging.
Model Three: Hybrid Sworn/Non-Sworn
Hybrid Ambulance Transport Services Sworn/Non-Sworn
Model Three employs a hybrid approach, integrating sworn firefighters and non-sworn (Single-Role) personnel to provide emergency ambulance transportation.
Proposed Staffing Configuration
This model can be adjusted based on Department needs, but the initial configuration includes:
• 1 firefighter-staffed 24-hour ALS units
• 1 single-role staffed 24-hour ALS units
Figure 41: Model Three Hybrid Sworn/Non-Sworn Staffing Costs Type of Personnel # of
Personnel Individual Total Annual Cost
Firefighter EMT Salaries 3 $62,956 $188,868
Firefighter EMT Benefits 3 $65,880 $197,640
Firefighter EMT Constant Staffing OT 276 PL Hours 276 PL Hours $26,851 Firefighter PM Salaries 3 $68,060 $204,180
Firefighter PM Benefits 3 $71,222 213,666
Firefighter PM Constant Staffing OT 276 PL Hours 276 PL Hours $29,028 AO EMT Salaries 4 $42,560 $170,240
AO EMT Benefits 4 $23,408 $93,632
AO EMT Constant Staffing OT 192 PL Hours 192 PL Hours $21,888 AO PM Salaries 4 $54,880 $219,520
AO PM Benefits 4 $30,184 $120,736
AO PM Constant Staffing OT 192 PL Hours 192 PL Hours $28,224 Estimated Staffing Cost $1,514,474
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 66 Benefits/Challenges – Model Three
Key Features
• Flexible Deployment: Allows for 24-hour units and 12-hour flex units, optimizing resource allocation.
• Balanced Workforce: 6 EMTs and paramedics from sworn ranks and 8 EMTs and paramedics from non-sworn ranks to ensure full system coverage.
Model Four: Adjusting Ambulance Staffing Hours
Adjusting ambulance staffing hours can trim costs in a larger system. Developing strategies that rely on a system status model, and a robust part-time staff can reduce overall costs and drive efficiency. In smaller systems, the adjustment of hours does not typically have the same effect. Below are seven examples of firefighter and ambulance operator models that could fill this critical role. • Firefighter Overtime Staffing – Firefighter overtime staffing is the current model in CFD.
Firefighters are staffed daily to fill the roles of Paramedic and EMT on 24-hour and 12-hour ambulances. Using this model is typically the most expensive staffing for partial shifts and can lead to firefighter burnout.
• AO Overtime Staffing – AO overtime staffing can reduce the overall costs to the City but should not be considered a long-term solution for on-going positions. • AO Part-time Staffing - Utilizing part-time Ambulance Operators (AOs) provides flexibility and can significantly lower operational expenses. This model allows coverage during peak hours, but consistent recruitment and scheduling are required to maintain reliability and prevent gaps in service.
• Firefighter Flex Staffing - Implementing flex staffing with firefighters enables the City to adjust workforce levels based on demand, particularly during peak periods. While this approach can optimize staffing efficiency, it may still incur overtime costs and require careful management to avoid staff fatigue.
• Single Firefighter Staffing - Assigning a single firefighter to an ambulance for certain shifts offers cost savings and increases scheduling flexibility. However, this model may impact coverage and response capabilities, as a solo firefighter may not be able to manage all emergency scenarios effectively.
• Single AO Staffing - Deploying a single AO per ambulance can further reduce costs and allow for more ambulances to be staffed during busy times. This approach relies heavily on the AO’s training and experience and may require additional support for complex incidents. • Flexible Hour Staffing - Adopting flexible hour staffing models enables coverage to be tailored to hourly call volume, ensuring resources are allocated when most needed.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 67 SUMMARY OF TRANSPORTATION MODELS
In the figure below, all personnel costs are listed with estimated costs for operational depreciation and operating costs.
Figure 42: Estimated Ambulance Transport Model Summary
Model Costs/Revenues Model One
Firefighter
Model Two
AO
Model Three
Hybrid
Personnel/Staffing Costs $1,720,468 $1,308,480 $1,514,474 Operating Depreciation (Estimated) $255,000 $255,000 $255,000 Operating Costs (Estimated) $220,640 $224,320 $222,480
Administration Costs $93,835 $93,835 $93,835
Total Operational Costs $2,289,943 $1,881,635 $2,085,789 EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 68 Section IV:
FEASIBILITY, OBSERVATIONS,
AND RECOMMENDATIONS
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 69 SYSTEM FEASIBILITY, CONSIDERATIONS,
& RECOMMENDATIONS
FEASIBILITY
Personnel Findings and Observations
Personnel #1
The current staffing of ambulance transport units using firefighters can be a cost effective way to increase staffing for fires and other emergencies while covering the needs of the ambulance transport system. Assuming two full-time 24-hour ambulance transport units, the Department is able to staff an additional twelve firefighters.
Personnel #2
Utilizing overtime to staff units can be an efficient way of staffing for short periods of time. The long term use of permenant overtime positions can lead to burn-out and firefighter fatigue.
Personnel #3
The projected salary compaction between potential non-sworn and sworn personnel could be a problem. Typically firefighters that have dual role (EMS/Fire Rescue) responsibilties are paid significanty more than single role ambulance operators. With overtime cost of non-FLSA exempt employees, that cost structure is upside down.
Equipment Findings and Observations
Equipment #1
Extending out the depreciation of units based on a reasonable use model could save the City.
Strategically rotating front-line and reservice units could extend the life of vehicles and other equipment.
Equipment #2
Each projected model placed a CPR device and other equipment on each unit to create a standard compilation of equipment. Changing the standard configuration could save the City in operating costs each year.
Equipment #3
The models assume all reserve units are fully stocked with medical and other supplies. Rotating supplies from front-line to reserve units and not maintaining fully stocked reserve units could save the City thousands in operating costs each year.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 70 System Findings and Oberservations
Systems #1
Understanding the valuation of the system and the actual cost recovery to the City is critical. The City contracts with Wittman, LLC, and they are a particularly reliable source to help better understand the current and projected cost recovery. CFD should establish monthly meetings with their Wittman representative to maintain current on changes in State and Federal regulations.
System #2
Each model is set up with a 10% Enterprise fund that could be set up to roll over into the budget. This cost recovery is important to maintain sustainability in the system. Cost recovery can fluctuate from year to year, and equipment needs can come up before anticipated depreciation dates. This fund can help to stabilize the system without burdening the general fund.
CONSIDERATIONS
Strategic Planning
A well-developed strategic plan will serve as a guiding framework for decision-making, aligning organizational resources with identified needs and long-term objectives. This approach promotes accountability, supports continuous improvement, and provides a mechanism for tracking progress.
The implementation of a strategic planning process will enhance overall service quality, strengthen community safety, and improve fiscal efficiency by ensuring that resources are allocated in a deliberate and data-driven manner.
Following the completion of the EMS analysis, the City and Fire Department should initiate a formal strategic planning process to ensure that the findings by participants are effectively developed into actionable outcomes. This process should establish clear priorities, define realistic timelines, and assign responsibility for implementation across the organization. By creating a structured roadmap, leadership can ensure that the recommendations identified in the analysis are not only acknowledged but systematically executed and monitored over time.
Utilization of Emergent Responses to Medical Incidents
Revising dispatch Emergency Medical Dispatch (EMD) protocols to incorporate clearly defined response modes should be pursued by leadership as an operational improvement. Currently, the dispatch center utilizes EMD protocols; however, these protocols do not include the assignment of response modes, such as lights and siren or non-emergent response, at the time of initial unit dispatch. This gap limits the ability to align response urgency with actual patient acuity and can contribute to unnecessary risk during emergency vehicle operations.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 71 To address this issue, all EMS response agencies dispatched, in coordination with the EMD physician advisor, should collaborate to formally establish response mode criteria for each EMD determinant and sub-determinant card. This process will ensure that response configurations are standardized, clinically appropriate, and consistent across the system. Incorporating response mode decisions into the initial dispatch process will enhance decision-making at the earliest point in the response continuum.
The anticipated outcome of this effort is to improve safety for both responders and the community by reducing unnecessary use of lights and sirens, while still ensuring timely and appropriate responses to high-acuity incidents.
Patient Care Reporting (PCR) System Documentation
Improving data collection through the 911 Computer-Aided Dispatch (CAD) system and the Department’s records management system (RMS) should be addressed by leadership as a short-term priority. The current assessment of service demand relied primarily on a limited number of data sources, including internal RMS records, CAD data, and call volume information reported through AP Triton survey tables. Additionally, the available dataset provided in this study spanned only a threeyear period and did not include certain critical performance elements, such as turnout time, which restricted the depth and reliability of the analysis.
Enhancing data collection practices and ensuring consistency between CAD and RMS systems will significantly improve the accuracy and completeness of operational data. Reliable data is essential for evaluating system performance, identifying trends, and making informed decisions regarding resource deployment and service delivery. This improvement can be achieved with minimal monetary impact by leveraging existing city staffing and focusing on standardizing data entry, improving data integration, and reinforcing quality assurance processes.
ALS Response Necessity
Increasing the use of a statistically based quality management program should be pursued by leadership as a mid-term priority. The findings from this evaluation suggest that existing data systems may support both program expansion and potential budgetary enhancements; however, they also highlight opportunities for improvement in data collection, documentation, and analytical practices.
CFD currently utilizes ESO Solutions for patient care reporting, which has the capability to export data into Microsoft Excel when documentation is entered by a provider accurately. This functionality allows for efficient data interrogation and the development of meaningful performance evaluations.
By strengthening the use of statistical analysis within a formal quality management framework, CFD can transition toward a more evidence-based approach to evaluating clinical performance and system effectiveness. Reliable, data-driven insights provide objective measures of the level of care delivered and can inform decision-making related to training, protocols, and resource allocation. This initiative can be implemented with minimal monetary impact, relying primarily on existing staff time dedicated to improving documentation practices, data analysis, and continuous quality improvement processes.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 72 The criticality identified in the service delivery analysis section reinforces the continued need for an ALS response model. However, future staffing configurations may benefit from the strategic and limited deployment of Paramedic/EMT-Basic units. The data suggests that incorporating a BLS transport unit could enhance overall ALS system capacity by preserving advanced resources for higher-acuity incidents. Additional analysis is necessary to fully evaluate the effectiveness and operational impact of implementing BLS ambulance transport within the system.
Call Processing Performance Outcomes
Improving call processing time in coordination with the Dispatch Center should be addressed by leadership as a priority initiative. This effort requires close collaboration with dispatch personnel to align performance with established benchmarks outlined in National Fire Protection Association standards, specifically NFPA 1750. These standards identify call processing time as the interval from call acceptance at the dispatch center to the notification of responding units and establish clear performance expectations: 90 percent of high-acuity incidents should be processed within 60 seconds, incidents requiring Emergency Medical Dispatch (EMD) or special assistance within 90 seconds, and 99 percent of all incidents within 120 seconds.
The available data indicates that current performance is significantly outside of these benchmarks, with a 90th percentile call processing time of five minutes and seventeen seconds between 2023 and 2025. This extended processing time represents a critical gap in system performance, as delays at this stage directly increase total response time and can negatively impact outcomes in time-sensitive emergencies.
A comprehensive review of call processing workflows, staffing, training, technology, and EMD protocols should be analyzed leadership to identify the root causes of these delays. Enhancements may include improved call-taking procedures, strengthened quality assurance processes, optimization of dispatch configurations, and potential technology upgrades. By addressing these factors, the system can achieve more efficient call handling, resulting in reduced total response times and improved overall service delivery. The monetary impact of this initiative will vary depending on the underlying causes of the delays, but may range from minimal, if improvements are process-driven, to more substantial if staffing or system.
Relying Solely on Ambulances to Deliver all Components of Emergency Medical Response is not Cost-Effective
Performing a cost-benefit analysis of medications and procedures administered by CFD should be undertaken by leadership as a mid-term initiative. Any staffing configurations, equipment, supplies, or clinical interventions that are not explicitly required by regulatory mandates or established industry standards should be systematically evaluated to determine their overall value to the organization and the community it serves.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 73 Gap analysis for response demand areas should seek to identify alternative health services. As identified in this study, the two boarder entry facilities generate nearly one-third of CFD annual EMS indents. This results in system utilization requiring the addition of resources. Financially, attempts to negotiate with federal agencies should seek compensation commensurate to the system investments by CFD to provide services.
Analysis should incorporate a data-driven, statistical approach to assess the effectiveness, frequency of use, patient outcomes, and associated costs of each resource or procedure under consideration. By doing so, CFD can ensure that its clinical practices and resource allocations are aligned with evidencebased outcomes and operational efficiency. The monetary impact of this initiative is expected to be minimal, as it can be accomplished primarily through the allocation of existing staff time.
RECOMMENDATIONS
Staffing
Single-Role / Dual-Role Model:
24-hour Units – 2 Units (17,520 hours)
12-hour Units – 0 Units (0 hours)
Unit Hours = 17,520 hours
This outcome is based on the available data and information provided by Calexico Fire Department for this study. As identified in the preceding considerations, this recommendation has potential impacts to current effective response force capabilities, culture, deployment, surge capacity, and labor implications.
The best route to determining whether the limited financial gains or benefits of this hybrid staffing model are beneficial should be critically analyzed in focus discussions facilitated through a comprehensive public safety strategic planning process. Investing in an inclusive internal and external stakeholder group would help the City and Fire Department look into future needs and not rely on a snapshot of issues, simply providing a short-term resolve.
Transport Fees
The City of Calexico, as a public agency operating under 201 rights of the California Health and Safety Code (Division 2.5), should maintain a structured and consistent process for establishing ambulance transport fees that aligns with industry standards and supports a financially sustainable EMS system.
At a minimum, the City should conduct an annual review of its transport rates.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 74 Transport rates and projected collections must be reasonably correlated to the full cost of service delivery, including both direct and indirect program costs, to ensure fiscal integrity and defensibility of the rate structure. In establishing and updating these rates, the City shall ensure compliance with California Proposition 26, including the requirement that fees not exceed the reasonable cost of providing the service and are not used to generate general revenue.
Updated ambulance transport rates shall be presented to and approved by the City Council no later than January 1 of each year in compliance with healthcare billing requirements.
Based on a comparison with regional providers, as identified in Figure 20, Calexico’s current rates are materially below prevailing market levels. Achieving alignment with the regional average would require a significant rate adjustment. The figure below outlines the estimated impact on cost recovery under adjusted rate scenarios.
Figure 43: Estimated Impact on Cost Recovery with Adjusted Rates Model Costs/Revenues Average BLS Bill Average ALS Bill Estimated Cost Recovery
Current $1,560 $1,789 $1,675,886
30% increase $2,028 $2,325 $1,759,822
50% Increase $2,340 $2,683 $1,815,885
75% Increase $2,730 $3,130 $1,885,921
100% Increase $3,120 $3,578 $1,917,718
PP-GEMT Non-Federal Share Payments
The City is currently participating in the PP-GEMT Program and receiving enhanced reimbursement for transported Medi-Cal patients. As part of program participation, the City is responsible for paying the applicable Non-Federal Share (NFS) and State administrative fees.
At this time, the City is not remitting these required payments. In practice, this results in other participating agencies across the State absorbing a greater share of the overall program costs in order to maintain program operations. While the program continues to function under the current structure, its long-term sustainability depends on consistent participation and cost-sharing among all agencies.
Although the City is currently avoiding approximately $273,000 in annual expenditures, there is a broader consideration regarding the ongoing stability of the PP-GEMT Program. If participation trends were to shift or if agencies reassess the balance between costs and reimbursements, there could be implications for the continuation of the program and the associated supplemental revenue, which is estimated at approximately $700,000 annually for the City.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 75 In light of these considerations, AP Triton recommends that the City evaluate incorporating its PPGEMT Non-Federal Share obligations into the Ambulance Program budget and consider establishing transport rates sufficient to support these costs. This approach would better align program participation with long-term financial planning and help support overall program stability.
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 76 Section V:
APPENDIX
EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 77 APPENDIX A: TABLE OF FIGURES
Figure 1: City of Calexico Data........................................................................................................... 3 Figure 2: CFD Service Locations for the Community ........................................................................... 6 Figure 3: Fire Station 1 Facility Review................................................................................................ 6 Figure 4: Fire Station 2 Facility Review................................................................................................ 7 Figure 5: CFD Annual Responses (2025)............................................................................................. 8 Figure 6: CFD EMS Service Demand (2025)......................................................................................... 9 Figure 7: Ambulance Utilization (2025)............................................................................................. 10 Figure 8: Calexico Fire Department Response Mode to EMS Incidents (2025) .................................... 10 Figure 9: Calculated Number of Ambulances by Day/Hour ............................................................... 11 Figure 10: Service Demand by Month (2025)..................................................................................... 12 Figure 11: Service Demand by Day of the Week (2025)...................................................................... 13 Figure 12: Service Demand by Hour of the Day (2025)....................................................................... 13 Figure 13: Incident Volume by Address (2025) .................................................................................. 14 Figure 14: Response Time Continuum.............................................................................................. 16 Figure 15: Summary of Performance Goals ...................................................................................... 17 Figure 16: CFD Response Performance 90th Percentile (2025)........................................................... 17 Figure 17: Population Projections (2025–2030)................................................................................. 19 Figure 18: Projected Service Demand (2026–2030)........................................................................... 20 Figure 19: Estimated Allowable Charges .......................................................................................... 25 Figure 20: Transport Service rates.................................................................................................... 27 Figure 21: Payor Mix Percentage & Transport Volume ....................................................................... 30 Figure 22: Payor Mix Percentage ...................................................................................................... 30 Figure 23: Authorized Calexico Fire Department Rates for Services................................................... 31 Figure 24: Transportation Reimbursement Calculation Estimator ..................................................... 31 Figure 25: Estimated Payor Mix Reimbursement............................................................................... 32 Figure 26: Determining Adequate UHU 24-hours/12-hours ............................................................... 38 Figure 27: UHU / Medical Aid Information......................................................................................... 40 Figure 28: UHU / Unit Coverage ....................................................................................................... 41 Figure 29: Estimated Unit Needs per Call Volume............................................................................. 42 Figure 30: 2025 Employee Salaries .................................................................................................. 44 Figure 31: Current Daily and Annual Staffing Cost (no overtime)........................................................ 45 Figure 32: 24-Hour / 12-Hour Shifts.................................................................................................. 47 EMS VALUATION AND OPERATIONAL ANALYSIS | C ALEXICO FIRE DEPARTMENT 78 Figure 33: Overtime Pay Calculation ................................................................................................ 49 Figure 34: Administrative Overhead Positions .................................................................................. 50 Figure 35: Estimated Billing Percentage and Net Cost Recovery........................................................ 52 Figure 36: PP-GEMT Program Steps and Cycle.................................................................................. 55 Figure 37: PP-GEMT Cost/Cost Recovery Estimations 2026 .............................................................. 57 Figure 38: Potential First Responder Fee & Cost Recovery ................................................................ 60 Figure 39: Model One Firefighter Staffing Costs ................................................................................ 63 Figure 40: Model Two Ambulance Operator (AO) Staffing Costs ........................................................ 64 Figure 41: Model Three Hybrid Sworn/Non-Sworn Staffing Costs....................................................... 65 Figure 42: Estimated Ambulance Transport Model Summary ............................................................ 67 Figure 43: Estimated Impact on Cost Recovery with Adjusted Rates.................................................. 74