1 City of Merced Fire Department
99 E. 16th St.
Merced, CA 95340
2024 IN TERFACILITY
TRANSPORT AMBULANCE
FEASIBILITY STUDY
City of Merced Fire Department
2 AUTHOR
Robert R. Smith
Senior Management Analyst
City of Merced Fire Department
Background:
Rob has had the honor to serve 25 years in the local EMS system including 14 years in the county fire service.
During that time, he has held progressive roles consisting of: EMT, Paramedic, Field Training Officer (FTO), Paramedic Field Supervisor, Flight Paramedic, Operations Manager, Clinical Director, General Manager (Ground & Air/CCT), Merced County EMCC Member, EMS Assessment Committee Member, California Ambulance Assoc. Executive Board Member (Legislative Chair), Managed Medi-Cal Commissioner, EMS management consultant and Emergency Manager.
PREFACE
Over the past several years, the City of Merced Fire Department has witnessed an ever-decreasing level of ambulance service being provided by the county contracted ambulance provider. A variety of reasons for the decline have been presented by both the ambulance provider and the Local EMS Authority (LEMSA). The City of Merced Fire Department with a focus on improving the level of EMS service being provided, has started work on several initiatives aimed at addressing the EMS system challenges as they have been presented. One such initiative is the creation of a Interfacility Transport (IFT) ambulance. The task of this report is to provide a practical and experience-based study of the program’s feasibility.
City of Merced Fire Department
3 TABLE OF CONTENTS
Author ....................................................................................................................................................................... 2 Preface ..................................................................................................................................................................... 2 Executive Summary ................................................................................................................................................. 4 Introduction ............................................................................................................................................................... 5 purpose ............................................................................................................................................................... 6 Scope .................................................................................................................................................................. 6 Problem Statement................................................................................................................................................... 7 Merced County EMS System Assessment – Breif ............................................................................................... 8 System Parameters:....................................................................................................................................... 8 System Resources: ........................................................................................................................................ 8 System Demand: ............................................................................................................................................ 9 Payor Mix: as of 2018 RFP reporting ............................................................................................................ 9 Ambulance Operations Review ......................................................................................................................... 10 Feasibility Assessment ........................................................................................................................................... 12 Options .............................................................................................................................................................. 12 Option #1 BLS (EMT)(EMT) ......................................................................................................................... 12 Option #2 ALS (EMT)(Paramedic) ............................................................................................................... 13 Option #3 CCT (RN) add-on ........................................................................................................................ 14 Cost vs. Revenue Analysis ............................................................................................................................... 15 Projected Operating Cost: ........................................................................................................................... 15 Projected revenue: ....................................................................................................................................... 16 Capital expenditures .................................................................................................................................... 17 Requirements .................................................................................................................................................... 18 EMS System Impact: projected .............................................................................................................................. 19 Recommendations ................................................................................................................................................. 20 Recommended actions: ............................................................................................................................... 20 Option Recommendation: Staffing Model .................................................................................................... 20 Staffing recommendation: ............................................................................................................................ 21 Transport Agreement recommendation: ...................................................................................................... 21 Ambulance Billing Company recommendation: ........................................................................................... 21 Definitions:.............................................................................................................................................................. 22 Relationship to other documents:........................................................................................................................... 23 Acknowledgements ................................................................................................................................................ 24 Exhibit# 1 ................................................................................................................................................................ 25 Exhibit # 2 ............................................................................................................................................................... 26
City of Merced Fire Department
4 EXECUTIVE SUMMARY
BRIEF HISTORY:
The California EMS Act created the State EMS Authority (CEMSA) in 1980 and placed the responsibility of EMS program development and management including EMS system design on the individual counties via the local emergency medical services authority (LEMSA). The EMS act and subsequent other legislation set standards and requirements on county contracts with ambulance providers but did allow for the continuance of preexisting ambulance provider contacts/agreements. The current ambulance provider in Merced County started operations in 1948 as a family-owned local business. In 2001 Merced County LEMSA conducted the first of three competitive bids for Exclusive Operating Area (EOA) contracts with the most recent in 2020 and no change in provider. In 2015 the local provider was purchased by a Nevada based not for profit ambulance provider.
SUMMERY OF CURRENT EVENTS :
The most resent Merced County ambulance provider and 2PASP contract started in 2020, it is a five-year contract with options for extensions to a maximum of ten years. The LEMSA has elected not to extend the current contract, reporting contract non-compliance (breach) by the provider.
Both the County LEMSA and the contracted ambulance provider have presented multiple reasons or causes leading to the non-compliance and ultimately reduced service via extended response times. One cause highlighted for the extended ambulance response times are hospital patient turn over delays (APOT). Also known as “wall time” this is the amount of time ambulance crews spend waiting in the local emergency room until they can turn over patient care to hospital staff and then respond to additional request for service (911 calls).
Not unique to Merced County APOT has been an identified issue in every California LEMSA. The negative effects of APOT have been steadily progressing since the acronym was first coined in 2015. The more rural and/or economically challenged the area the greater the effect APOT has on the EMS system.
In-hospital causes of APOT can be traced primarily to a process known as “Through Put” or the ability of the hospital to treat and discharge patients making room for the next patient. APOT occurs when more patients are coming into the hospital than are leaving the hospital. Ironically many of those patients have completed their treatments and are pending discharge and/or transport by ambulance.
So, what effect does APOT have on The City of Merced Fire Department and ultimately the residents of Merced.
Currently, the fire department is not an ambulance provider and therefor fire department personnel are not stuck on wall time in the local ER. Merced City Fire is however a first responder agency, responding to medical emergencies with EMT qualified personnel. These personnel often arrive to the requesting address within moments of the request and are essential in providing basic emergency medical care prior to the ambulance and advanced medical care arrival. With increasing APOT occurrences resulting in protracted ambulance response times the fire personnel are subsequently delayed on scene often for greater than 30 mins. With limited response resources system wide the compounding effects can have severe consequences.
Plan of action is to address the root cause of APOT within the capabilities and allowable actions available to the fire department. One such action as addressed in this report is to create and staff an IFT ambulance program:
with the intent of improving hospital through put, decreasing ambulance APOT, decreasing ambulance response times, reducing fire resource Time on Task (TOT) and improved Point of Contact (POC) level of service.
City of Merced Fire Department
5 INTRODUCTION
In order to accurately review the IFT program’s feasibility, several prerequisites had to be studied.
1. Current EMS system assessment
a. System demand analysis
i. Peak demand times
ii. System resource availability
b. Hospital demand
i. Peak demand times
ii. Request types (BLS, ALS, CCT)
c. Payor mix
2. IFT program operational modeling
a. Staffing model
i. Stocking requirements (supplies and equipment)
3. IFT fiscal modeling
a. Cost analysis
i. Capital expenditures.
1. Vehicle
a. Medical equipment: i.e. (EKG, Gurney)
ii. Overhead cost:
1. Dispatch
2. Medical director
3. Management
4. Billing
iii. Staffing cost
1. Wages
2. Uniforms
3. Training
iv. Revolving cost
1. Disposable supplies
2. Fuel
3. Maintenance
b. Revenue forecast
i. Call volume
ii. Payor mix
iii. Cost per call – average billable per call
City of Merced Fire Department
6 PURPOSE
The intent of this report is to provide the appropriate City personnel and leadership with the most current, reliable and reasonable information available in order to make informed decisions on the IFT program. To that end: all processes used to calculate the operational and fiscal performance use the following principal. All projected expenditures are calculated using high-mean averages and all projected revenues are calculated using low- mean averages. All fiscal forecast contained in this report are intended to represent minimum baselines.
Successful implementation of the IFT program may slightly out preform this modeling methodology but should not be expected.
SCOPE
The scope of this report shall be limited to:
The City of Merced Fire Department: IFT ambulance project.
1. Projected:
a. Cost of the project.
b. Revenue of the project.
c. System impacts of the project.
2. Required information:
a. Mercy Hospital Merced
1. Demand analysis
b. Merced County EMS
1. System assessment data
2. Regulatory requirements
c. City of Merced
1. Operational analysis
d. SEMSA/Riggs Ambulances Service (Merced County Contracted Ambulance Provider).
1. System assessment data
e. CEMSA
1. Regulatory requirements
City of Merced Fire Department
7 PROBLEM STATEMENT
As briefly outline in the executive summary ambulance APOT via hospital through-put is one of several factors effecting ambulance response times and thus increasing fire personnel TOT. In contrast to other factors outlined by the LEMSA this is one that The City of Merced Fire Department believes it can affect and do so with positive results.
By deploying an IFT ambulance which is allowable under LEMSA regulation and is not prohibited under the current ambulance provider contract the IFT program is intended to increase hospital through-put by transporting patients ready for discharge to their respective destinations, thereby freeing up additional hospital beds and reducing APOT, freeing up ambulance resources to respond to awaiting request for service.
It is the statement of the IFT program developers that the IFT program should have a positive effect on system delays, providing downstream improved ambulance response times to the people of Merced, while being financially self-sufficient.
To most accurately determine the feasibility of such a program this report will take a zoom out then in approach, looking at EMS from a State & County level before zooming in on the projected effectiveness of an IFT program and its possible effects on local APOT.
From this point several options will be outlined with operational and cost modeling concluding with one or more recommendations for consideration.
City of Merced Fire Department
8 MERCED COUNTY EMS SYSTEM ASSESSMENT – BREIF
SYSTEM PARAMETERS:
The Merced County EMS system covers nearly 2,000 square miles, with a population of approximately 281,000 residents. Covering twelve townships and six incorporated cities spread along two major corridors (hwy 99 & hwy 33) also known locally as Eastside and Westside as they relate geographically. Of the population centers Merced City is by far the largest with the 2020 census reporting 86,333 residents. Merced City also accounts for the largest portion of EMS request for service and is home to the larger of the Counties two remaining hospitals.
SYSTEM RESOURCES:
- Ambulance Providers:
1. SEMSA/Riggs (ALS/BLS)
2. West-Side Hospital District (ALS/BLS)
3. Mutual Aid Request (ALS)
- First Responders:
1. City of Merced Fire (EMT)
2. Merced County Fire/Cal-Fire (EMR)
3. Atwater City Fire (EMR)
4. Livingston City - Volunteer (EMR)
5. Los Banos City Fire (EMT/EMR)
- HEMS:
1. Cal-Star / Reach – Merced & Modesto
2. Mercy Air – Merced
3. PHI – Modesto
- Hospitals:
1. Basic Emergency Care
a. Mercy Medical Center – Merced
b. Memorial Hospital Los Banos
2. STEMI Center
a. Emanual Medical Center – Turlock
b. Doctors Medical Center – Modesto
c. Memorial Medical Center – Modesto
3. Trauma Center
a. Level 2:
i. Doctors Medical Center – Modesto
ii. Memorial Medical Center – Modesto
b. Level 1:
i. Community Regional Medical Center – Fresno
ii. UC Davis Medical Center – Sacramento
4. Pediatric Center:
a. Level 2:
i. Valley Childrens Hospital – Fresno/Madera
b. Level 1:
i. UC Davis Medical Center – Sacramento
- Mental Health Facilities:
1. Merced County BHRS
a. See: exhibit (1) for detail
City of Merced Fire Department
9 SYSTEM DEMAND:
- EMS Request 2023: 35,539
1. Priority 1:
a. System wide: 15,873
b. Area of Merced City: 8,569
2. Priority 2:
a. System wide: 9,649
b. Area of Merced City: 5,574
3. Priority 3:
a. System wide: 10,017
b. Area of Merced City: 5,938
4. IFT:
a. Mercy Merced:
i. BLS
1. Local (>50miles): No longer tracked by MEMSA.
2. Out of County: No longer tracked by MEMSA.
3. BHRS: No longer tracked by MEMSA.
ii. ALS: 971
iii. CCT: No longer tracked by MEMSA.
5. Mutual Aid: (ambulance)
a. Requested: 656
b. Received: 34
6. City of Merced Fire Department:
a. Request:
i. EMS: 8,123
ii. Non-EMS: 3,670
PAYOR MIX: AS OF 2018 RFP REPORTING
- Commercial payor: 9.8%
- Medicare: 42.6%
- Medi/Medi: not reported.
- Medi-Cal (Medicaid) 43.4%
1. Managed Care: not calculated.
2. Fee for service: not calculated.
- Self-pay: 3.7%
- Facility Responsible: 0.5%
City of Merced Fire Department
10 AMBULANCE OPERATIONS REVIEW
Ambulance basics:
IFT ambulance are staffed with a variety of options and equipment as you will see in the options section later in this document. For the purpose of this report all ambulances are staff, stocked and equipped at the standards set by California Health and Safety Code title 22, California Highway Patrol Ambulance guidelines and Merced County EMSA. Additionally, the ambulance will undergo annual certification by Merced County Weights and Measures for accurate mileage calculation.
Ambulance staffing requires a minimum of two trained personnel and are typically limited to three staffed personnel. One staff member is required for vehicle operations (driving) and one crewmember in the patient compartment (back) for patient care (attendant). The attendant is also the crewmember responsible receiving the discharge report, providing the turnover report at destination and for the Patient Care Report (ePCR). During normal operations these personnel will switch calls based on rotation or level of care (BLS vs ALS).
Once staffed it is the crews responsibility to ensure that the ambulance is fueled and in operational order (vehicle chassis, power train, wheels & tires…) all warning devices are operating properly (turn signals, brake lights, head lights, red lights, amber lights, sirens…), all medical equipment is present, in working order and functioning properly (gurney, batteries, suction units, BP cuff, oxygen regulator, c-spine equipment…), all supplies are stocked and current (oxygen, bandages, cleaning supplies…).
Hospital request for service:
Once hospital staff (under the direction of a physician) has identified a need for patient transfer and transport services. They will next find an appropriate receiving facility capable of accepting the patient. The receiving facility can vary from the patients home to advanced care hospital. If the patient is being transport home no accepting physician is required however a PCS signed by the sending physician is required and the family often needs to be present either to open the residents and/or provided continued monitoring and care. When transporting to another facility the process is slightly more complicated: an accepting physician is required, and that facility often has a specific bed assignment and possible time slot requirement.
The hospital department staff will then contact the ambulance provider (call center) to arrange transport. Staff will provide patient demographics, billing information (pre-authorization), medical complaint, level of service needed, receiving facility (destination). The ambulance provider call center will in return provide an Estimated Time of Arrival (ETA).
Responding Resources:
The ambulance provider call center will then dispatch the appropriate ambulance crew, a variety of dispatch platforms are available. The call center will provide HIPAA compliant information to the crew and assign a dispatch priority. Once at the facility the crew will take their gurney and any needed equipment into the facility, contact the sending personnel (RN, LVN) receiving a verbal report along with accompanying documentation.
The staff report may include special considerations i.e., contact precautions, so patient contact is not made until a complete report is received. The patient is assessed prior to transfer to ambulance gurney and switching of monitoring and/or medical support equipment (EKG and Oxygen). The patient is secured to the gurney with approved safety and restraint devices and transferred to the ambulance for transport. During transport the attendant will continue to provide medical monitoring (assessment) and treatment to the receiving facility.
City of Merced Fire Department
11 Patient Transfer of Care:
Once at the receiving location the attendant will provide a verbal care report to the accepting staff (RN) and transfer the patient from the gurney to the hospital bed or other specified location. Upon completion of the assignment, it is the attendant’s responsibility to accurately and timely complete ePCR.
The ePCR serves two purposes: (one) as a legal accounting of the patients’ medical care provided by the ambulance crew, (two) as a record for billing purposes in revenue collection.
Once patient care is transferred to the receiving facility the crew will clean and restock the ambulance for readiness of the next assignment prior to departing.
Ambulance Billing for Service:
Once completed the ePCR is forwarded to the ambulance billing provider for review (pre-billing) and subsequent billing application to the appropriate payor. The ambulance billing process is extremely complex and requires specialized training and continuous education/updates. There are a few aspects that warrant mentioning here:
first the turn around time on billing can take several months, the billing staff can only bill under the appropriate level of service as determined by CMS and maybe less than requested by the sending facility, for example the sending facility requested an ALS transport, the ambulance provider sent an ALS ambulance, the paramedic was the attending but per CMS guidelines: circumstances only justify billing for BLS level of service. In addition, to billing for the level of service, the mileage from the sending to receiving facility is also billed on transports leaving the City of Merced.
City of Merced Fire Department
12 FEASIBILITY ASSESSMENT
OPTION S
OPTION #1 BLS ( EMT)(EMT)
1.1 Per Diem (8hr shift coverage)
- This option is the most cost effective with reduced overtime pay and increased flexibility.
Staffing would consist of a BLS IFT ambulance staffed in 8hr increments allowing for augmentation of covered hours: including 8hr/ 16hr/ 24hr.
1. Disadvantages: increased shift change rotations
1.2 Per Diem (12hr coverage)
- This option would staff a BLS IFT ambulance for a scheduled 12 hours per day base on peak demand times. Historically peak demand times in Merced are from 1000 – 2200. This would not provide coverage for the remaining 12-hour period there by reducing cost and personnel/staffing requirements. Note: this option does require changes in the draft Patient Transport Services Agreement with Mercy Hosp.
1.3 Per Diem (24hr coverage)
- This option would staff two 12hr shifts (day & night) resulting in 24hrs of IFT coverage. Normal staffing for this type of staffing would have the day shift scheduled from 0700-1900 and night from 1900-0700 both shifts returning to station for crew change, fuel and restock 30 mins prior to shift completion.
1. Advantages: This does allow some sharing of the peak demand times between day and night shift; however, the day shift does retain much of that time frame. The shift times can be adjusted to compensate. With reduced volume in the late evening and early morning there is potential for mutual aid request and 911 system support, noting: that would require additional agreements and no reliable volume. The ambulance provider does historically have reduced staffing levels over night/early morning and the addition of a BLS transport unit within the City of Merced is likely to have value.
City of Merced Fire Department
13 OPTION #2 ALS (EMT)(PARAMEDIC)
- Note: under the current Merced County Ambulance Provider contract, the contracted provider has exclusive rights to ALS ambulance staffing. Meaning that only the contracted ambulance provider can staff and deploy Paramedic staffed ambulances for transport.
- The contracted ambulance provider may at its own choosing with MEMSA consent contract that right with an outside provider. This contracting does not fall within the parameters of this report; therefore, calculations are based on industry standards and may not included any or all requirements that could be included in such an agreement.
2.1 Per Diem (8hr or 12hr coverage)
- This option would staff an ALS ambulance (1-EMT & 1-Paramedic) for a scheduled 8 or 12 hours per day base on peak demand times. Historically peak demand times in Merced are from 1000 – 2200. This would not provide coverage for the remaining hours of operation there by reducing cost and personnel/staffing requirements. Note: this option does require changes in the draft Patient Transport Services Agreement with Mercy Hosp.
2.2 Per Diem (24hr coverage) (BLS/ALS)
- This would be a mix between option 1.1/ 1.2/ 1.3 and 2.1 with only 8/12 of the 24hrs covered by a paramedic ALS, and the remaining 12/16hrs BLS.
2.3 Per Diem (24hr coverage)
- This option would staff two 12hr shifts (day & night) of (1-EMT & 1-Paramedic) resulting in 24hrs of ALS ambulance coverage. Normal staffing for this type of staffing would have the day shift scheduled from 0700-1900 and night from 1900-0700 both shifts returning to station for crew change, fuel and restock 30 mins prior to shift completion.
2.4 On Call
- This would incorporate the addition of one paramedic to option 1.1 or option 1.2 for the duration of a specific task or assignment. (2-EMTS & 1-Paramedic)
1. The advantage: would result in only supplying ALS services as needed. a. May have increased potential with the implementation of the First Response Paramedic Program.
2. The disadvantage: currently it would require the prescheduling of staff and request for service.
City of Merced Fire Department
14 OPTION #3 CCT (RN) ADD -ON
- CCT description:
CCT provides for the transport of high acuity patients such as ICU level patients. These patients require advanced interventions that are above the scope of EMTs or Paramedics. High acuity patients are extremely personnel and time extensive and tax hospital resources often to the breaking point. Additionally, these patients often require services not locally available and must be transferred to a facility with higher level of care capabilities. Hospitals are known to take extraordinary measures to facilitate these transfers including utilizing HEMS or reducing the interventions to ALS levels to accomplish the transport thou not preferred.
1. The advantages of providing CCT services as an add-on are:
a. Increased system impact: as mentioned above high acuity patients have multiplication effect on hospital resources often consuming 2-3 times the amount of standard patients.
b. Increased revenue: CCT are compensated at much higher rates than BLS or ALS non-emergency transports.
c. Phased approach: CCT coverage can be phased in or out as part of the previous options and is not a stand-alone option.
d. While the BLS portion of the ambulance is covered by MEMSA the RN portion of the crew and treatment does not fall under jurisdiction of MEMSA.
2. The disadvantages:
a. In addition to staffing RNs and establishing treatment protocols, CCT requires additional advance medical equipment, medications, and supplies.
3.1 On Call
- This would incorporate the addition of one CCT-RN to option 1.1 or option 1.2 for the duration of a specific task or assignment. (2-EMTS & 1-CCT-RN)
1. The advantage: would result in only suppling CCT services as needed.
2. The disadvantage: would require the prescheduling of staff and request for service.
3. Above stated advantages and disadvantages in the description apply.
3.2 Partnership
- As the title implies: This requires partnering with the local hospital or locally approved CCT transport provider for CCT-RN as needed staffing.
1. The advantages over 3.1.
a. Decrease staffing and RN staff training requirements. i. Note: consider (3.1 On Call) during transport.
b. Allows for emergent response and transport.
c. Can be expanded beyond RN to included respiratory therapist (RT) or specialty nurses such as L&D
d. Hospital provided CCT equipment.
2. The disadvantages over 3.1.
a. Staff may not be CCT certified.
b. Staff may not be oriented to ambulance operations.
i. Answer: work with the hospital to create an approved list of nursing personnel and provided ambulance orientation.
c. Extra care must be taken during the billing process to ensure CMS compliance.
City of Merced Fire Department
15 COST VS. REVENUE ANALYSIS
PROJECTED OPERATING COST:
Option: 1 (1.1) (1.2) (1.3)
8-hour shift schedule BLS unit cost per hour is = $ 121.25 - 8-hour coverage cost = $ 970.00
- 16-hour coverage cost = $1,940.00
- 24-hour coverage cost = $2,910.10
12-hour shift schedule BLS unit cost per hour is = $ 141.45 - 12-hour coverage cost = $1,697.55
- 24-hour coverage cost = $3,395.10
Options: 2 (2.1) (2.2) (2.3)
ALS unit cost per (1:1)
8-hour shift schedule ALS unit cost per hour is = $ 134.65 - 8-hour coverage cost = $1,077.20
- 16-hour coverage cost = $2,154.40
- 24-hour coverage cost = $3,231.65
-
12-hour shift schedule ALS unit cost per hour is = $ 157.10
- 12-hour coverage cost = $1,885.15
- 24-hour coverage cost = $3,772.30
Option: 2 (2.4)
Paramedic Add-on (2:1):
- Add-on per scheduled hour = $ 74.00
Option: 3 (3.1) (3.2)
CCT Add-on (2:1):
- (3.1) Add-on per scheduled hour = $ 210.00
- (3.2) Add-on per scheduled hour = $ 140.00
City of Merced Fire Department
16 PROJECTED REVENUE:
For the purpose of revenue calculation, the latest reported payor mix was applied towards the current fee schedules resulting in the average paid by all payor types. No add-on fees were applied to the calculations due to insufficient data and the unreliability of add-on fee application. Additionally, PP-GEMT funds were not calculated in the estimated average revenue. The PP-GEMT fund is only applied to emergency and CCT/SCT transports and requires higher and more reliable emergency transport volumes to be viable.
Average IFT BLS revenue per call = $ 325.36.
Average IFT ALS revenue per call = $ 350.17
Average ALS/BLS Emergency revenue per call = $ 493.05 Average CCT/SCT revenue per call = $1,657.84
CALL VOLUME REQUIREMENTS:
Minimum average transport volume per duration to achieve financial stability.
BLS IFT
- 8hr Shifts: 8 hours 16 hours 24 hours.
- 12hr Shifts: 12 hours 24 hours.
City of Merced Fire Department
17 CAPITAL EXPENDITURES
Note: Each level of care builds upon the proceeding level of care.
Ambulance:
- Vehicle: 140,368
- Graphics: 2,250
- Cradle Point: 2,434
- Radios: 5,413
Total: 150,465 150,465
Equipment:
BLS:
Gurney: 24,866 24,866
Power Load: 27,339 27,339
Stair Chair: 4,047 4,047
BLS (Base) Total: 56,252 + 56,252
206,717
ALS:
ECG Monitor: CCT/ALS Life Pack 15 40,721 40,721
ALS Total: 40,721 + 40,721
247,438
CCT:
Ventilator: Zoll 15,000 15,000
IV Infusion Pumps (6): Sapphire 2,400 14,400
Tocodynamometer: Edan F6 6,800 6,800
HFNC: Airvo 2: 7,500 7,500
CCT Total: 43,700 +43,700
291,138
Amortization
Five-year amortization of capital expenditures: with BLS as the base amount and cumulative additions:
Total Cost: 1:5yr amortization
BLS: 206,717 41,344
ALS: (YTD) 247,438 + 8,145 49,489
CCT: 291,138 + 8,740 58,229
City of Merced Fire Department
18 REQUIREMENTS
Key requirements:
- Ambulance Billing Company:
Note: Medical Billing and Ambulance Billing are not the same specialty.
An experienced Ambulance Billing company with Certified Ambulance Billing Personnel is required.
Key attributes of a qualifying Ambulance Billing Company:
a. Local Experience:
The organization should reside with-in the State of California and be familiar with Medi-Cal billing, including the local managed Medi-Cal provider (CCAH). With near 50% of all
transports covered by Medi-Cal and a high majority of those transports falling under (CCAH) local experienced is crucial in revenue cycle reliability.
b. Government Organization Experience:
Experience billing ambulance claims for one or more of the following organization types:
1. Special District (Healthcare District)
2. Municipality (City or County)
Unit Hour Utilization: UHU or calculated workload:
- UHU is calculated using assigned durations per assignment divided by the shift duration. A calculated average UHU of 0.35 – 0.45 (8hr/12hr) is considered ideal for financial stability and crew health.
1. Local transport = 1 Unit Hour (UH)
2. Out of area transport = 1 + travel time = UH
Example: Mercy – DMC (1+ 1.5 + 1.5) = 4 UH
A 12hr shift that completed 5 local transports:
( 5UH / 12hrs )= 0.416 UHU
- The shorter the shift duration, the higher the acceptable UHU.
With 8hr shift durations a regular UHU of 0.50 or 0.625 is still consider safe for employee health while they would not be considered healthy for 12hr shifts.
City of Merced Fire Department
19 EMS SYSTEM IMPACT: PROJECTED
System impact:
- Measurable impact:
In order to determine any potential system impact, first a baseline had to be established.
Sansio ePCR software was used with controlled parameters excluding (non-emergency, Standby, Cancelled enroute) and including (Patient evaluated, care provided, care turned over to EMS).
1. Sansio Report: On Scene - To In Service (ePCR Times) Avg = 21.09 mins (TOT) 06/01/23 – 05/31/24
a. Noted: Outliers
Elapsed Time: Number of calls
31-40 minutes 15
41-50 minutes 9
51-59 minutes 4
1-1:50 hours 5
- What does success or a positive system impact look like:
1. Decreased Avg (TOT)
2. Decreased Outlier Occurrences
Note: With no changes in system resources the impact provided by a signal resource should be relatively small (as it applies to the whole system average) yet measurable.
Note: It is possible that system resources are reduced during the case period. As the LEMSA reported not tracking the contracted ambulance providers “unit staffing” and no other reliable means are available to insure system resource consistency.
City of Merced Fire Department
20 RECOMMENDATIONS
RECOMMENDED ACTIONS:
Based on the specifics covered in this report and EMS system review the operation of a BLS IFT ambulance is both operationally and fiscally feasible and may have a positive impact on the level of EMS service provided to the residents and guest of Merced City.
OPTION RECOMMENDATION: STAFFING MODEL
- Option: (1.1) BLS (2) 8-hour shifts for a total of 16 hours of daily coverage.
Advantages:
a. Expandable
i. Hours
The hours of operation can be expanded to 24 hours or
reduced to 8 hours based on realized demand.
ii. Scope
The scope of the unit can be expanded “add-on” for the
level of service required without a maintained elevated cost.
b. Fiscal
i. Reduced operating cost:
8/16 vs 12/24 = -($509,267) per year.
8/24 vs 12/24 = -($ 169,756) per year.
c. Crew Workload:
i. Provides for a UHU within acceptable parameters while still achieving fiscal stability.
- Option: (3.2) CCT add-on Partnership
During the introductory period (proof of concept) option (3.2) is recommended, however should the program prove viable and continued then a transition to Option (3.1) with a maintained partnership agreement for special circumstances is recommended.
- No recommendation for ALS IFT Staffing:
At this time the LEMSA ambulance provider contract does not allow for Paramedic staffed ALS ambulance services. However, an agreement with the current contracted ambulance provider should be considered.
City of Merced Fire Department
21 STAFFING RECOMMENDATION:
During the introductory period it is recommended to staff ambulance crews using per-diem employee model. This allows for greater program flexibility while reducing any undo displacement and/or stress on the work force.
TRANSPORT AGREEMENT RECOMMENDATION :
1. Recommend: Enter into an Interfacility Transport agreement with Mercy Hospital – Merced aka: Common Sprit to include BLS, ALS (when available) and CCT level of service. Consider changing the current proposed draft agreement to reflect the recommended hours of coverage, include a CCT ambulance rate and allow for response exemptions.
2. Recommend: A partnership agreement with the hospital and/or a locally approved CCT transport provider to achieve CCT level of service.
3. Recommend: Seek additional local transport agreements including Merced County BHRS to improve demand and community impact.
AMBULANCE BILLING COMPANY RECOMMENDATION:
Recommend: Conduct an expedient search for a contracted ambulance billing provider meeting the following requirements.
1. California Based (required)
2. Medi-Cal Billing Experience (required)
3. Public Ambulance Provider Experience (required)
4. Central California Alliance for Health (CCAH) Experience (preferred)
5. PP-GEMT Experience (preferred)
City of Merced Fire Department
22 DEFINITIONS:
APOT: Ambulance Patient Off-load Time ( Wall Time)
EMS: Emergency Medical Services
CMS: Center for Medicare Service (regulatory authority for Medicare and Medicaid) Medi-Cal: The California version of Medicaid
BHRS: Behavioral Health and Recovery Services
IFT: Interfacility Transfer by ambulance
BLS: Basic Life Support – EMT level training
EMT: Emergency Medical Technician
EMR: Emergency Medical Responder
ALS: Advanced Life Support – Paramedic level +
CCT: Critical Care Transport – Registered Nurse staffed with either BLS or ALS ambulance crew. Also known as: Specialty Care Transport (SCT) HEMS: Helicopter EMS Provider “Med Evac”
ePCR: electronic Patient Care Report: includes Patient demographics, medical history, medications, allergies, interventions, assessments and an accounting of events.
STEMI: “ST” segment Elevated Myocardial Infarction “Heart Attack.” STEMI Center: Interventional Cardiac Services Hospital Per Diem: employee
A part-time employee with no regular schedule or guaranteed hours, the per diem employee may pick and choose the dates and time slots they are willing or able to work.
On-Call: employee
A per diem employee who is compensated for reliable staffing availability. Typically reserved for higher level practitioners who are as needed additions to augment an ambulance crew’s capability for a specific transport.
Priority Dispatch:
Priority 1 – Code 3 Response immediately life threatening (code blue) (chocking) Priority 2 - Code 3 Response: imminently life threatening (chest pain) Priority 3 – Code 2 Response: emergent not imminently life threating (flu symptoms)
Code Response:
Code 3: Red lights & sirens, no delays, direct route of travel.
Code 2: No red lights & siren, no delays, direct route of travel.
Code 1: As conditions and needs allow.
City of Merced Fire Department
23 RELATIONSHIP TO OTHER DOCUMENTS:
- RFP 7310 Merced County Ambulance Provider
1. Point of review for technical compliance.
- Patient Transport Services Agreement (draft)
1. Point of review for operating requirements
- City of Merced Resolution 2023-82 (pay scales)
1. Point of review for cost calculations.
- HCPCS pay codes for 2024. (online)
1. Point of review for revenue calculations
- California DHCS PP-GEMT report (online)
1. Point of review for revenue calculations (911)
- City of Merced Fire Department Rescue Paramedic/ALS Program Implementation Guide.
1. Point for review for operational modeling.
- 2016 Merced County EMS Assessment (PWW)
1. Point of review for system comparison.
- Sansio “Call Times – On Scene to In Service” Report
1. Project evaluation tool
City of Merced Fire Department
24 ACKNOWLEDGEMENTS
Thank you to:
City of Merced Fire Department:
- Interim Fire Chief Casey Wilson
- Battalion Chief Mickey Burnelli
- Janet German
- Lori Mileur
Merced County Emergency Medical Services Authority:
- Mike Garret
Mercy Medical Center – Merced
- Dale Johns
- Maranda Hall
- Jatinder Mann
City of Merced Fire Department
25 EXHIBIT# 1
Behavioral Health & Recovery Services – Merced County
- Calendar year 2023:
1. Total transports:
a. Local destinations:
With in Merced County
b. Out of County:
With in an adjacent county:
c. Long Distance:
Beyond adjacent counties:
- BHRS receiving destinations / distance from Merced City / number of transports:
City Facility Distance Transports
1. Merced Marie Green 0 miles 210
2. Delhi CPT 20 miles 02
3. Modesto Doctors Behavioral 40 miles 88
4. Fresno CRMC 55 miles 05
Cedar Vista 55 miles 31
5. Sacramento Sierra Vista 110 miles 48
Heritage Oaks 118 miles 63
6. Bakersfield 165 miles 19
7. Santa Rosa Santa Rosa BHS 180 miles 167
City of Merced Fire Department
26 EXHIBIT # 2
Medicare Ambulance Base Rates: 2024 (Merced County, California)
Level of Service Billing Code Base Rate
BLS Non-Emergency A0428 $298.88
BLS Emergency A0429 $478.20
ALS Non-Emergency A0426 $358.60
ALS Emergency A0427 $567.87
CCT / SSC A0434 $971.36
Mileage paid only after 7 miles.
https://hcpcs.codes/fee-schedule/ambulance
Medi-Cal Ambulance Base Rates:
Level of Service Billing Code Base Rate PP-GEMT
BLS Non-Emergency A0428 $118.20 $0
BLS Emergency A0429 $118.20 $946.92
ALS Non-Emergency A0426 $118.20 $0
ALS Emergency A0427 $118.20 $946.92
CCT / SSC A0434 $118.20 $946.92
Note: The PP-GEMT add-on is only available to those agencies participating in the PPGEMT fund “funding”. https://www.dhcs.ca.gov/provgovpart/Pages/PPGEMTIGT
City of Merced Fire Department
27 Notes: