EMS Transportation & Optimization Study National City Fire Department
2 Projected Unit Deployment ............................................................................................. 74 Costs of the EMS System ....................................................................................................... 75 Personnel Costs ................................................................................................................. 75 Administrative Costs .......................................................................................................... 76 Overhead Costs ................................................................................................................ 78 Additional Start-Up Costs ................................................................................................. 80 Cost Recovery & FEE REVIEW ............................................................................................... 82 Analysis of Potential Revenue Streams ........................................................................... 82 Federal Reimbursement Programs .................................................................................. 84 SECTION III: EMS SYSTEM DELIVERY MODELING ......................................................... 91 EMS Delivery Options & Strategies ...................................................................................... 92 EMS Transport Service Models ......................................................................................... 92 System Deployment Recommendations ....................................................................... 93 System Costs ...................................................................................................................... 94 Public-Private Partnership ................................................................................................ 98 Facilities .............................................................................................................................. 98 Deployment Models ......................................................................................................... 99 Governance Structure .................................................................................................... 116 Regulatory Compliance and Legal Considerations ................................................... 116 Impact of California Health and Safety Code Sections 1797.201 & 1797.224 ......... 117 Strategic Collaboration with LEMSA & EMSA ............................................................... 117 Startup Costs .................................................................................................................... 118 Hiring and Orientation .................................................................................................... 118 Summary of Transportation Models .............................................................................. 120 Appendix A: Table of Figures ............................................................................................ 122
EMS Transportation & Optimization Study National City Fire Department 3 ACKNOWLEDGMENTS
AP Triton Consulting wishes to extend its sincere appreciation to each of those individuals whose contributions and assistance made this project possible.
Our sincere appreciation is extended to each of you…
National City Dignitaries
Ron Morrison
Mayor
Marcus Bush
Vice Mayor
Luz Molina
Council Member
Jose Rodriguez
Council Member
Ditas Yamane
Council Member
National City
Scott Huth
City Manager
Bruce Foltz
Finance Director
Alicia Hicks
Human Resource Director
Barry Schultz
City Attorney
Ashlin Lutes
Deputy City Attorney
Richard Romero
Assistant City Attorney
National City Fire Department
Sergio Mora
Fire Chief
Brian Krepps
Division Chief
Robert Hernandez
Division Chief
James Stiles
Battalion Chief
Matt Lucas
Battalion Chief
Scott Robinson
Battalion Chief
Brian Viora
Captain of EMS
Jeremy Day
Captain
International Association of Fire Fighters, Local 2744
Jeremy Day
President
…and each of the EMTs, Paramedics, Firefighters, officers, and support staff who daily serve the residents and visitors of National City.
EMS Transportation & Optimization Study National City Fire Department
4 EXECUTIVE SUMMARY
The National City Fire Department (NCFD) delivers a high-performing Emergency Medical Services (EMS) system that provides rapid, advanced prehospital care across a dense, urban service area of approximately 7.3–9.1 square miles. Through an integrated model of fire-based Advanced Life Support (ALS) first response, private ambulance partnership, and countywide dispatch coordination, NCFD ensures timely emergency care for more than 10,000 incidents annually—nearly half of which are medical in nature.
System Valuation and Reimbursement Potential
The financial assessment of National City’s EMS system reveals a significant opportunity for enhanced cost recovery and long-term fiscal sustainability under a public provider framework.
Using National City’s 2024 ALS transport rate of $4,606 and projected 2025 volume of 5,598 transports, the system’s gross annual billing is estimated at $20.8 million, with net collectible revenue of approximately $4.83 million (23% of billings). The payer mix, dominated by Medicare (44%) and Medi-Cal (33%), creates a structural ceiling on reimbursement potential under private operations. However, as a public provider, NCFD would gain access to the Public Provider Ground Emergency Medical Transport (PP-GEMT) program and related federal Medicaid enhancements.
PP-GEMT participation would elevate Medi-Cal reimbursement from $339 per trip (private) to $1,158 per trip (public), a differential of roughly $819 per transport. At National City’s projected volume, this equates to an annual fiscal benefit exceeding $900,000, directly improving cost recovery and reducing dependence on the General Fund. Additionally, public operation enables eligibility for supplemental programs such as the Quality Assurance Fee (QAF), further improving overall Medi-Cal recovery rates.
In total, the combined effects of PP-GEMT participation and improved reimbursement structures could increase annual EMS system revenue to approximately $4.8 million, positioning a city-operated model as not only clinically superior but also financially advantageous over private subcontracting.
EMS Transportation & Optimization Study National City Fire Department
5 Operational Framework and Performance
NCFD maintains 24-hour ALS coverage through a three-platoon staffing structure of 14 personnel per shift. Fire-based paramedics staff all frontline units—Engines 31 and 34, Truck 34, and Squad 33—enabling early intervention in cardiac arrest, trauma, and respiratory emergencies prior to ambulance arrival.
Private transport integration is achieved through American Medical Response (AMR) units co-located at Stations 31 and 34, ensuring rapid transition from on-scene stabilization to hospital delivery. This model provides seamless care coordination while mitigating service delays.
Dispatch operations are managed through the National City Police Department’s PSAP and the regional Emergency Command and Data Center (ECDC), which utilizes Emergency Medical Dispatch (EMD) and Enhanced 9-1-1 (E911) technology to deliver pre-arrival instructions and triage.
Facilities, Apparatus, and Readiness
NCFD operates three stations—Station 34 (good condition), Station 31 (fair), and Station 33 (temporary/poor). While the system’s geographic distribution supports effective coverage, Station 33’s temporary status and capacity limitations constrain future EMS expansion. Construction of a permanent Station 33 capable of housing three apparatus and eight staff is recommended if municipal ambulance operations are pursued.
Frontline apparatus (two engines, one aerial quint, and one squad) are rated in good- to-excellent condition. The department adheres to a Capital Replacement Plan that aligns with the Economic Theory of Vehicle Replacement, ensuring optimal timing for apparatus renewal to minimize lifecycle costs.
Service Demand and Resource Requirements
Between 2020 and 2024, EMS incidents rose 6.7%, despite a stable population base (~55,000 residents). Peak demand occurs between 8:00 AM and 8:00 PM, representing
63.7% of total daily volume. GIS analysis confirms adequate 4- and 8-minute travel-time coverage, though concurrency data indicates growing pressure on daytime capacity.
EMS Transportation & Optimization Study National City Fire Department
6 Modeling identifies a need for four to five ambulances during peak daytime hours and two to three units overnight, maintaining an optimal Unit Hour Utilization (UHU) of 0.35 to balance responsiveness and personnel endurance.
Financial Model Comparison and Findings
Five delivery options were evaluated:
Model Description Unit Hour
Cost
Net
Recovery Outcome
#1 Firefighter
Model
Sworn firefighter-
paramedic staffing $214.12 –$173K High cost,
premium service
#2 Ambulance
Operator Model
Non-sworn
EMT/paramedic staffing $182.93 +$510K Most sustainable
#3 Hybrid
(Sworn/Non-Sworn) Mixed staffing $194.98 +$246K Balanced flexibility #4 Subcontracting Private provider
oversight $318.66 –$2.46M Unsustainable
#5 Hybrid
Subcontracting City/private partnership $244.27 –$833K Transitional, moderate deficit
The Ambulance Operator Model (Model #2) produces the strongest fiscal outcome, yielding a $509,799 annual surplus while maintaining service reliability. When combined with PP-GEMT reimbursement, the system achieves the highest long-term return on investment, providing both fiscal stability and operational control.
Strategic Recommendations
• Adopt a Public Provider Framework—Transition to city-operated ambulance transport to maximize PP-GEMT and QAF reimbursement.
• Leverage Supplemental Funding Programs—Pursue ongoing participation in PP- GEMT, IGT, and Medicaid enhancement programs to sustain solvency. • Implement an Enterprise Fund Model—Allocate 10% of annual EMS operating costs to reserve for future capital replacement and payer variability. • Invest in a Permanent Station 33—Expand EMS housing capacity to support additional ambulances and personnel.
• Maintain Data-Driven Oversight—Use 90th-percentile performance metrics and continuous QA/QI to guide deployment and financial adjustments.
EMS Transportation & Optimization Study National City Fire Department
7 Conclusion
National City’s EMS system demonstrates strong operational readiness and exceptional fiscal potential under a public provider model. By leveraging its ALS infrastructure, optimizing staffing efficiency, and capturing federal and state reimbursement enhancements through PP-GEMT, the City can transform its EMS program into a self- sustaining enterprise. This approach not only strengthens financial independence but also enhances clinical performance, community trust, and long-term service reliability.
EMS Transportation & Optimization Study National City Fire Department
8 SECTION I:
EVALUATION OF THE EMS SYSTEM
EMS Transportation & Optimization Study National City Fire Department
9 OVERVIEW OF THE COMMUNITY
& EMS SYSTEM
National City, California
Geography
National City is located in southern San Diego County, just southeast of downtown San Diego and along the coast of San Diego Bay. The city covers approximately 7.3 square miles of land and an additional 1.8 square miles of water. It is bordered by the communities of San Diego, Lincoln Acres, Bonita, and Chula Vista, and lies just a few miles from the U.S.-Mexico border. The city benefits from its proximity to major highways and regional transit corridors, making it an important residential and commercial hub within the South Bay region.
Population
As of the 2020 U.S. Census, National City had a population of approximately 58,460, slightly down from 58,582 in 2010. More recent estimates in 2023 suggest the population stands at about 55,960. Despite the slight decline, National City remains one of the most densely populated municipalities in San Diego County, with around 7,600 residents per square mile.
Demographics
National City is a highly diverse and multicultural community. Approximately 66% of residents identify as Hispanic or Latino (of any race), making it a majority-Latino city.
There is also a significant Asian population—most notably Filipino Americans—who have played a central role in the city's cultural and economic fabric for decades. In fact, National City is recognized as having one of the highest concentrations of Filipino Americans in the United States. Other racial and ethnic groups include White (non- Hispanic), multiracial individuals, and smaller populations of African American and Native American residents.
The median age of residents is approximately 36 years old. Many households are multigenerational, and Spanish is widely spoken throughout the city. This linguistic and cultural diversity is reflected in local schools, small businesses, and community events.
EMS Transportation & Optimization Study National City Fire Department
10 Income and Housing
The median household income in National City is estimated at $64,248, which is below the California state average. Nearly 14% of the population lives below the federal poverty line. Homeownership is relatively low compared to national averages— approximately 70% of households are renter-occupied. The median home value is around $580,900, reflecting significant growth in property values despite income constraints. The rental market is strong, driven by both demand and proximity to San Diego’s economic core.
Community Identity and Lifestyle
National City presents a dense, walkable, and urban-suburban character, with many family-owned businesses, cultural centers, parks, and community institutions. The city has been recognized as one of the most walkable in the San Diego region. It features a blend of historic identity and evolving infrastructure, including efforts to revitalize the waterfront and commercial corridors. Politically, the community leans liberal, and its civic institutions reflect a focus on equity, public health, and inclusive economic development.
Governance
National City operates under a council–manager form of government, which combines elected policy leadership with professional administration. The City Council serves as the legislative body and is composed of an elected Mayor, Vice Mayor, and three Councilmembers. The Mayor is elected at-large, and the four council members are elected by districts within the city. The Vice-mayor position is rotated through the council members. These officials are responsible for setting policy, adopting ordinances, approving the city budget, and appointing key administrative roles.
The City Manager, appointed by the City Council, acts as the chief executive officer for the city. This individual is responsible for implementing council policies, managing daily operations, and overseeing all city departments, including Fire, Police, Finance, Planning, Public Works, and Community Services. The City Manager also develops the city’s annual budget and supervises department heads.
In addition to the council and city manager, the city appoints a City Clerk and a City Treasurer. The City Attorney is appointed and provides legal counsel to the council and city departments, drafts legal documents, and represents the city in litigation.
EMS Transportation & Optimization Study National City Fire Department
11 National City’s governance model emphasizes transparency, community engagement, and efficient administration, while enabling the elected officials to focus on legislative matters and the appointed City Manager to provide stable, professional leadership in daily operations.
Project Initiation
This project was initiated to conduct a comprehensive evaluation of the City’s ambulance service area and to develop future-facing EMS system modeling options.
The overarching purpose is to improve the emergency medical services system's operational, financial, and clinical performance while aligning with community expectations and regulatory standards.
The National City Fire Department (NCFD) has identified several key goals that form the foundation of this analysis. Central to these is the objective of creating long-term system stability by establishing operational control over EMS deployment—ensuring that first responder and ambulance resources are used efficiently and in a coordinated manner. Financial sustainability is also a core priority, with a focus on reinvesting system revenue to improve service delivery rather than operating within a for-profit model.
In support of these goals, the project also explores opportunities to access supplemental federal funding streams that can offset local costs and support system enhancements. Improved coordination across all EMS components is a critical outcome, with an emphasis on ensuring that the appropriate resources reach patients in a timely, clinically appropriate, and cost-effective manner.
Recognizing the rapid evolution of health care and technology, the project seeks to leverage innovations in service delivery and data integration to better meet the expectations of diverse communities. Maintaining or improving ambulance unit availability and response times is essential, as is designing a system that is financially viable, clinically effective, and responsive to current and emerging public health needs.
The analysis also addresses workforce development and community outreach as important byproducts of system reform, creating new employment pathways and strengthening local engagement. Importantly, the proposed EMS system design is grounded in both clinical research and community-identified needs. It incorporates equity-focused strategies that specifically address the needs of vulnerable and underserved populations, ensuring that access to high-quality EMS care is consistent across all segments of the community.
EMS Transportation & Optimization Study National City Fire Department
12 National City Fire Department
The National City Fire Department serves the City of National City, covering approximately 7.3 to 9.1 square miles and protecting a resident population of around 58,460. On weekdays, the city’s population swells to over 100,000 due to commuter and commercial traffic, as well as activity from the Port of San Diego and Naval Base San Diego. In addition to serving National City, the department provides contracted fire protection services to the Lower Sweetwater Fire Protection District and supports nearby regional assets through mutual aid partnerships.
The department is organized into three core divisions: Fire Administration, Community Risk Reduction, and Fire Operations. These branches work in coordination to deliver leadership, code enforcement, public education, and 24/7 emergency response.
NCFD operates out of three fire stations: Station 31 and Station 34 are full-service stations, while Station 33 is a smaller squad house positioned to enhance coverage in high-density areas.
Staffing includes 42 full-time sworn personnel operating on a 24-hour shift schedule, distributed across three rotating platoons. Each shift includes 14 firefighters, including a Battalion Chief, Captains, Engineers, and Firefighter-Paramedic/EMTs. The department maintains a modern apparatus fleet that includes two engines, a ladder truck, a squad unit, a battalion chief vehicle, and a cross-staffed OES Type 1 engine. Additionally, the department co-houses ambulances operated by American Medical Response (AMR) to strengthen EMS capabilities.
The National City Fire Department responds to over 10,000 emergency incidents annually. These include structure fires, wildland fires, medical emergencies, vehicle accidents, hazardous materials calls, and rescues. The department is deeply involved in fire prevention efforts, public safety education, and community outreach, and adheres to a mission centered on professionalism, service, and collaboration.
NCFD has a long and distinguished history dating back to its founding as a volunteer fire company in 1887. It became a paid, professional agency in the early 20th century and began its contract with the Lower Sweetwater Fire Protection District in 1982. The department maintains active automatic-aid relationships with agencies such as San Diego Fire-Rescue, Chula Vista Fire Department, Bonita-Sunnyside Fire Protection District, and Federal Fire San Diego, ensuring regional coordination and response readiness during major incidents.
EMS Transportation & Optimization Study National City Fire Department
13 NCFD Organizational Structure
NCFD is structured to provide efficient, coordinated fire protection, emergency medical services (EMS), and community risk reduction across the city’s 7.3 to 9.1 square miles. The department is organized into three primary divisions: Fire Administration, Community Risk Reduction, and Fire Operations.
The department is led by the Fire Chief, who oversees all strategic, operational, and administrative functions. The Fire Prevention, managed by a Division Chief who serves as the Fire Marshal, handles inspections, code enforcement, plan review, and community risk reduction programs. Fire Administration provides leadership, budgeting, training coordination, and administrative support for daily operations.
The Operations Division manages frontline response and includes two full-service fire stations—Station 31 and Station 34—along with Station 33, a smaller squad house used for enhanced coverage. Staffing includes 42 full-time sworn personnel, who rotate through three 24-hour shift platoons. Each shift typically consists of one Battalion Chief, four Captains, three Apparatus Engineers, and six Firefighter-Paramedics or Firefighter- EMTs.
The department operates a fleet of emergency response units, including two fire engines, one aerial ladder truck, a squad unit, a Battalion Chief command vehicle, and a cross-staffed Office of Emergency Services (OES) Type 1 engine. All fire apparatus are staffed with at least one paramedic, ensuring that Advanced Life Support (ALS) is available on every response unit.
EMS is a core component of NCFD’s service delivery. The department co-locates American Medical Response (AMR) ambulances at Fire Stations 31 and 34, allowing for seamless integration between fire-based first response and private ambulance transport. This model enhances patient care and system efficiency.
NCFD participates in regional dispatch operations through San Diego Fire-Rescue’s Emergency Command and Data Center (ECDC), also known as “Metro.” This shared dispatch system coordinates incident responses across multiple neighboring jurisdictions and ensures rapid communication during major emergencies.
The department also maintains mutual aid agreements and provides contract service to the Lower Sweetwater Fire Protection District, expanding its operational reach beyond the city limits. Overall, NCFD’s organizational structure supports a versatile, responsive, and community-focused fire and EMS delivery system.
EMS Transportation & Optimization Study National City Fire Department
14 National City Fire Department Emergency Medical Services The National City Fire Department (NCFD) provides a comprehensive, advanced-level EMS system that serves the residents and visitors of National City with rapid and high- quality emergency medical care. Operating within a dense, urbanized area of just under 10 square miles, NCFD’s EMS strategy is built around paramedic-level service on all front-line units, seamless collaboration with transport providers, and consistent staffing supported by an efficient three-platoon system.
All fire suppression units operated by NCFD—including Engine 31, Engine 34, Truck 34, and Squad 33—are staffed with Firefighter-Paramedics or Firefighter-EMTs. This ensures that Advanced Life Support (ALS) care is available at the scene of an emergency within minutes of dispatch, regardless of the transport unit's arrival. These ALS crews are capable of performing cardiac defibrillation, advanced airway management, intravenous drug administration, and other life-saving interventions before and during patient transport.
To support patient transport and extend its EMS coverage, NCFD co-locates American Medical Response (AMR)ambulances at Fire Stations 31 and 34. These units are operated by private paramedic crews but function as part of the countywide EMS deployment system. The integration of fire-based ALS first response with private ambulance transport provides rapid stabilization followed by timely hospital delivery, which is especially critical given National City’s high EMS call volume.
Each 24-hour shift is staffed with 14 responders, including a Battalion Chief, Fire Captains, Engineers, and Firefighter-Paramedics. This personnel complement is sufficient to maintain ALS coverage across the city’s two primary fire stations and one squad station. NCFD responds to over 10,000 emergency calls per year, with nearly half of those being medical incidents, making EMS a core component of daily operations.
The department also prioritizes EMS training, continuing education, and quality assurance. All paramedic personnel are certified through the County of San Diego EMS system and adhere to countywide protocols and performance benchmarks.
Additionally, public outreach, CPR education, and prevention efforts round out NCFD’s commitment to community health and pre-hospital care.
EMS Transportation & Optimization Study National City Fire Department
15 Study Area
The following figure illustrates the study area, service-area boundaries of NCFD, and locations of each of the fire stations.
Figure 1: NCFD Overall Service Area
Community EMS Education—National City Fire Department
The National City Fire Department plays an active role in educating the public on emergency medical response, offering structured programs designed to improve community preparedness and bystander intervention during medical emergencies.
One of the department’s primary public education initiatives includes CPR/AED and First Aid training courses, which are offered to residents for a nominal fee. These courses provide hands-on instruction in basic life-saving techniques such as cardiopulmonary resuscitation, automated external defibrillator use, and basic wound care.
EMS Transportation & Optimization Study National City Fire Department
16 Classes are taught by NCFD firefighter-paramedics and EMTs who bring real-world experience to the instruction, ensuring the training aligns with local EMS protocols and best practices. These sessions are hosted at local fire stations and are part of a broader effort to reduce response gaps during critical medical incidents by empowering community members to act before emergency personnel arrive.
In addition to formal classes, community education is integrated into the department’s daily operations. Firefighters are expected to participate in public outreach efforts, including school visits, station tours, group instruction, and neighborhood events. These interactions not only raise awareness about emergency preparedness but also foster trust and engagement between the fire department and the public.
EMS education is deeply embedded in NCFD’s mission. The department prioritizes community knowledge as a key component of public safety and views education as a shared responsibility. This commitment ensures that residents are not only informed but are also equipped to assist during medical emergencies, potentially improving survival rates and outcomes.
EMS Transportation & Optimization Study National City Fire Department
17 Emergency 9-1-1 Dispatch Capabilities—National City, CA National City’s emergency communications system is designed to provide efficient, coordinated public safety dispatch for law enforcement, fire, and emergency medical services (EMS). The system operates as a two-tiered structure involving both local and regional agencies, ensuring timely call handling, resource deployment, and clinical triage.
At the local level, the National City Police Department’s Communication Center functions as the city’s Public Safety Answering Point (PSAP), receiving all 9-1-1 and non- emergency calls placed within city limits. This 24/7 facility is the first point of contact for emergency requests and is staffed by trained dispatchers who collect location and incident details, determine call type, and route the information to the appropriate responding agency. The system also supports text-to-9-1-1, providing an alternative for individuals who may be unable to speak during an emergency.
For fire and EMS incidents, calls are transferred to the Emergency Command and Data Center (ECDC)—a regional dispatch facility operated by San Diego Fire-Rescue. Often referred to as "Metro," the ECDC manages incident communications and unit deployment for multiple jurisdictions, including the National City Fire Department. This regional approach ensures uniform protocols, interagency coordination, and scalability during large-scale emergencies.
A key capability of the ECDC is Emergency Medical Dispatch (EMD). Dispatchers are certified to provide structured medical triage using standardized protocols. Based on the nature of the emergency, dispatchers can determine whether to send basic life support (BLS) or advanced life support (ALS) units, and they provide Dispatch Life Support (DLS)—such as CPR instructions or bleeding control guidance—while units are en route.
The system utilizes Enhanced 9-1-1 (E911) technology to automatically capture caller location and improve response accuracy, especially for mobile phone users. Regional dispatchers at the ECDC collectively handle more than 350,000 calls per year and coordinate over 200,000 incident responses. The integration of local call intake, regional coordination, and medically guided dispatch protocols ensures a high standard of care and efficiency across all emergency responses in National City.
EMS Transportation & Optimization Study National City Fire Department
18 CAPITAL FACILITIES, APPARATUS,
& EQUIPMENT
Apparatus and other vehicles, trained personnel, firefighting and emergency medical equipment, and fire stations are the essential capital resources necessary for a fire department to carry out its mission. No matter how competent or numerous the firefighters are, if appropriate capital equipment is not available for operations personnel, it would be impossible for the National City Fire Department to perform its responsibilities effectively. The essential capital assets for emergency operations are facilities, apparatus, and other emergency response vehicles. This section of the report assesses NCFD’s fire stations and frontline apparatus and ambulances.
Fire Station Features
Fire stations play an integral role in the delivery of emergency services for several reasons. To a large degree, a station’s location will dictate response times to emergencies. A poorly located station can mean the difference between confining a fire to a single room and losing the structure, or survival from sudden cardiac arrest. Fire stations also need to be designed to adequately house equipment and apparatus and meet the needs of the organization and its personnel.
Fire station activities should be closely examined to ensure the structure is adequate in both size and function. Examples of these functions can include the following:
• Kitchen facilities, appliances, and storage
• Residential living space and sleeping quarters for on-duty personnel (all genders) • Bathrooms and showers (all genders)
• Training, classroom, and library areas
• Firefighter fitness area
• The housing and cleaning of apparatus and equipment, including decontamination and disposal of biohazards
• Administrative and management offices, computer stations, and office facilities • Public meeting space
EMS Transportation & Optimization Study National City Fire Department
19 In gathering information from NCFD, AP Triton asked the department to rate the condition of its fire stations using the criteria from the following figure. The results can be seen in the following figures.
Figure 2: Criteria Utilized to Determine Fire Station Condition Excellent
Like new condition. No visible structural defects. The facility is clean and well-maintained. Interior layout is conducive to function with no unnecessary impediments to the apparatus bays or offices. No significant defect history. Building design and construction match the building’s purposes. Age is typically less than ten years.
Good
The exterior has a good appearance with minor or no defects. Clean lines, good workflow design, and only minor wear of the building interior. Roof and apparatus apron are in good working order, absent any significant full-thickness cracks or crumbling of apron surface or visible roof patches or leaks. Building design and construction match the building’s purposes. Age is typically less than 20 years.
Fair
The building appears to be structurally sound with a weathered appearance and minor to moderate non-structural defects. The interior condition shows normal wear and tear, but flows effectively to the apparatus bay or offices. Mechanical systems are in working order. Building design and construction may not match the building’s purposes well. Showing increasing age-related maintenance, but with no critical defects. Age is typically 30 years or more.
Poor
The building appears to be cosmetically weathered and worn with potentially structural defects, although not imminently dangerous or unsafe. Large, multiple full-thickness cracks and crumbling of concrete on the apron may exist. The roof has evidence of leaking and multiple repairs. The interior is poorly maintained or showing signs of advanced deterioration with moderate to significant non-structural defects. Problematic age-related maintenance and major defects are evident. It may not be well-suited to its intended purpose. Age is typically greater than 40 years.
EMS Transportation & Optimization Study National City Fire Department
20 National City Fire Department Stations
The following section lists the various features of NCFD’s fire stations.
Figure 3: Station 34
Address/Physical Location: 343 E. 16th St., National City, CA 91950 Structure
Date of Original Construction 2005
Owned or Leased by Agency Owned
Seismic Protection
Auxiliary Power Yes
General Condition Good
Number of Vehicle Bays Drive-through Bays 3 Back-in Bays 1 Total Square Footage 19,500
Facilities Available
Sleeping Quarters 11 Bedrooms 11 Beds 0 Dorm
Beds
Maximum Staffing Capability 13. Possibilities of putting in bunk or dual beds in what is ambulance crews’ room
Exercise/Workout Facilities 2
Kitchen Facilities 1
Individual Lockers Assigned Yes
Bathroom/Shower Facilities Yes
Office/Computer Stations Yes
Washer/Dryer Yes
Other Notable Features
Safety & Security
Station Sprinklered Yes
Smoke Detection Yes
Decontamination/Bio. Disposal Yes
Security System Yes
Vehicle Exhaust System Yes
Assigned EMS Units
Ambulance or Other Vehicle No. of
Staff Comments
Engine 34 4
Truck 34 4
Battalion 57 1
AMR Medic 417 2
EMS Transportation & Optimization Study National City Fire Department
21 Figure 4: Station 31
Address/Physical Location: 2333 Euclid Ave., National City, CA 91950 Structure
Date of Original Construction 1984
Owned or Leased by Agency Owned
Seismic Protection
Auxiliary Power Yes
General Condition Fair
Number of Vehicle Bays Drive-through Bays 0 Back-in Bays 2 Total Square Footage 5,400
Facilities Available
Sleeping Quarters 6 Bedrooms 6 Beds 0 Dorm
Beds
Maximum Staffing Capability 6
Exercise/Workout Facilities Yes
Kitchen Facilities Yes
Individual Lockers Assigned Yes
Bathroom/Shower Facilities Yes
Office/Computer Stations Yes
Washer/Dryer Yes
Other Notable Features
Safety & Security
Station Sprinklered No
Smoke Detection Yes
Decontamination/Bio. Disposal Yes
Security System Yes
Vehicle Exhaust System Yes
Assigned EMS Units
Ambulance or Other Vehicle No. of
Staff Comments
Engine 31 3
AMR Medic 418 2
EMS Transportation & Optimization Study National City Fire Department
22 Figure 5: Station 33
Address/Physical Location: 2005 E. 4th St. National City, CA 91950 Structure
Date of Original Construction 2017
Owned or Leased by Agency Owned
Seismic Protection
Auxiliary Power Yes
General Condition Poor
Number of Vehicle Bays Drive-through Bays 0 Back-in Bays 2 Total Square Footage 1,100
Facilities Available
Sleeping Quarters 3 Bedrooms 3 Beds 0 Dorm
Beds
Maximum Staffing Capability 4
Exercise/Workout Facilities Yes
Kitchen Facilities Yes
Individual Lockers Assigned Yes
Bathroom/Shower Facilities Yes
Office/Computer Stations Yes
Washer/Dryer Yes
Other Notable Features
Double-wide is a temporary station. We could
move workout equipment out of one room to
house a 4th person
Safety & Security
Station Sprinklered Yes
Smoke Detection Yes
Decontamination/Bio. Disposal No
Security System Yes
Vehicle Exhaust System No
Assigned EMS Units
Ambulance or Other Vehicle No. of
Staff Comments
Squad 33 2
EMS Transportation & Optimization Study National City Fire Department
23 Summary of the NCFD Fire Stations
The following figure is a summary list of some of the primary features of the three National City Fire Department fire stations.
Figure 6: Summary of the NCFD Fire Station Features (2022) Station Square
Footage
Apparatus
Bays
Maximum
Staffing
General
Condition
Station
Age
Station 34 19,500 4 13 Good 20 years
Station 31 5,400 2 6 Fair 41 years
Station 33 1,100 2 4 Poor 8 years
Totals: 20,600 8 23
As shown in the preceding figure, NCFD’s Station 34 and Station 31 exceed twenty years of service; however, they are listed in good/fair condition. Station 33 is considered a temporary station and has limited capacity for additional EMS apparatus and staffing. If NCFD expands services to include ambulance transport, the City should focus on a new Station 33 with the capacity to house at least three apparatus and eight staff.
NCFD Apparatus & Vehicles Inventory
Fire apparatus, ambulances, and other emergency response vehicles must be sufficiently reliable to transport Firefighters and equipment rapidly and safely to an incident scene. In addition, such vehicles must be properly equipped and function appropriately to ensure that the delivery of emergency services is not compromised.
As a part of this study, AP Triton requested that the National City Fire Department provide a complete inventory of its fleet (suppression apparatus, ambulances, command and support vehicles, specialty units, etc.). For each vehicle listed, NCFD was asked to rate its condition utilizing criteria described in the following figure—the results of which will be shown in the subsequent apparatus inventory figures.
EMS Transportation & Optimization Study National City Fire Department
24 Figure 7: Criteria Used to Determine Apparatus & Vehicle Condition Components Points Assignment Criteria
Age: One point for every year of chronological age, based on the date the unit was originally placed into service.
Miles/Hours: One point for every 10,000 miles or 1,000 hours Service:
1, 3, or 5 points are assigned based on service type
received (e.g., a pumper would be given a 5 since it is classified as severe duty).
Condition:
This category considers body condition, rust, interior
condition, accident history, anticipated repairs, etc. The better the condition, the lower the assignment of points.
Reliability:
Points are assigned as 1, 3, or 5, depending on the
frequency a vehicle is in for repair (e.g., a 5 would be assigned to a vehicle in the shop two or more times per month on average; while a 1 would be assigned if in the shop on average once every three months or less.
Point Ranges Condition Rating Condition Description
Under 18 points Condition I Excellent
18–22 points Condition II Good
23–27 points Condition III Fair (consider replacement)
28 points or higher Condition IV Poor (immediate replacement)
EMS Transportation & Optimization Study National City Fire Department
25 As shown in the following figure, NCFD maintains two frontline engines, one aerial, and several other vehicles. The following figure lists the department’s current frontline inventory.
Figure 8: NCFD Fleet Inventory (2022)
Radio
Call Sign
Type
(I, II, III, Other)
Chassis & Body
Manufacturers
Assigned
Station Year Condition
Engines & Aerials
Engine 34 Type I Arrow XT
Pierce Station 34 2024 Excellent
Engine 31 Type I Arrow XT
Pierce Station 31 2019 Good
Engine 34 Type I Arrow XT
Pierce Station 34 2011 Good
Engine 31 Type I Arrow XT
Pierce Station 34 2006 Good
Truck 34 Quint Arrow XT
Pierce Station 34 2015 Good
Truck 34 Quint Arrow XT
Pierce Station 34 2009 Good
Other Vehicles
Squad 33 Other 5500 Ram Station 33 2021 Good
Squad 33
(Reserve) Other Ford Station 33 2016 Good
The National City Fire Department maintains a number of apparatus in reserve, which includes Engines 31, 34, Truck 34, and Squad 33.
Apparatus Maintenance & Replacement Planning
No piece of mechanical equipment or vehicle is designed to last indefinitely. As apparatus and vehicles age, repairs become more frequent and complex, parts may become harder to source, and downtime for maintenance increases. Because fire protection, EMS, and other emergency services are critical to the community, minimizing downtime is a primary factor in determining apparatus replacement.
Given the high cost of fire apparatus and medic units, the City has developed a capital replacement plan. Fire departments commonly establish an expected life cycle for each vehicle, which provides a projected replacement date to support long-term planning and budget development.
EMS Transportation & Optimization Study National City Fire Department
26 In practice, using life-cycle projections for planning purposes—such as allocating replacement funding—can be beneficial while determining the replacement date based on maintenance records, performance evaluations, and operational reliability.
This approach allows the department to achieve greater cost-effectiveness without compromising service readiness.
Economic Theory of Apparatus Replacement
Some fire districts use the Economic Theory of Vehicle Replacement as a conceptual model for apparatus management. According to this theory, as a vehicle ages, its capital value decreases while operating costs rise. The combination of these factors creates a total cost curve, indicating that the optimal time to replace an apparatus occurs when operating costs begin to exceed capital costs. This optimal replacement point is not a single date but typically falls within a range.
Timing replacements within this window allows the department to achieve the greatest cost efficiency. If equipment is not replaced in a timely manner, the perceived savings from delaying purchases can be offset by increasing maintenance and repair costs.
Fire officials who assume that deferring replacements will help balance the budget should consider two potential consequences:
1) Costs shift from the capital budget to the operating budget. 2) Overall fleet costs may increase due to higher maintenance and repair expenditures.
The following figure illustrates the Economic Theory of Vehicle Replacement.
Figure 9: Economic Theory of Vehicle Replacement
EMS Transportation & Optimization Study National City Fire Department
27 Despite its net effect on current apparatus and vehicle costs, deferring replacement purchases unquestionably increases future replacement spending needs. The deferral may also impact operational capabilities, including the safe and efficient use of apparatus.
Potential Future Ambulance Serviceability
An important consideration for NCFD is the cost associated with the future replacement of ambulances. The recommended lifespan of an ambulance depends on its type, usage, and regulatory guidance, and there are widely accepted standards in the fire/EMS industry:
Type I and Type III Ambulances (chassis-based, modular patient compartment):
• Typical lifespan: 6–10 years or 100,000–150,000 miles. • Many agencies aim to replace at 8–10 years for Type I/III due to escalating maintenance costs, reliability concerns, and safety standards.
Type II Ambulances (van-style, non-modular):
• Typical lifespan: 4–6 years or 100,000 miles.
• These have a shorter service life because they often have less robust chassis and limited customization for EMS operations.
Factors affecting replacement timing:
• Annual mileage and engine hours.
• Frequency and cost of repairs/maintenance.
• Vehicle downtime affecting response readiness.
• Compliance with federal or state safety and EMS regulations. • Technological advancements (e.g., updated patient care equipment, electronic systems).
Industry best practice: Most fire/EMS agencies follow a “life-cycle replacement” model, where an ambulance is planned for replacement before maintenance costs exceed capital cost efficiency, often around 8–10 years for Type I/III vehicles.
EMS Transportation & Optimization Study National City Fire Department
28 NCFD Fleet Maintenance
The National City Fire Department employs dedicated city mechanics to perform a portion of its vehicle maintenance. However, these staff members are not certified as Emergency Vehicle Technicians (EVT) under NFPA 1910: Standard for the Inspection, Maintenance, Refurbishment, Testing, and Retirement of In-Service Emergency Vehicles and Marine Firefighting Vessels. Some maintenance tasks and major repairs are outsourced. NCFD’s vehicles undergo routine preventative maintenance, and pump tests are conducted annually in accordance with NFPA 1910.
If the department begins providing ambulance transport, at least one additional mechanic with EVT certification will be necessary to maintain the expanded fleet and ensure compliance with applicable standards.
Capital Medical Equipment
The National City Fire Department maintains five 2024 Zoll X Series® Advanced cardiac monitor/defibrillators. These devices are equipped and capable of providing cardiac
monitoring, defibrillation, 12-lead ECGs, and monitoring of SpO
2, etCO2, carbon monoxide (CO), blood pressure,
and temperature.
EMS Transportation & Optimization Study National City Fire Department
29 SERVICE DEMAND OVERVIEW
This section provides National City with an overview of key response data. It is designed to help the city assess recent emergency medical services (EMS) and ambulance performance, establishing a baseline for performance expectations. National City, the Fire Department, county officials, and political leaders can use this information to understand how their decisions, policies, and external factors influence overall performance.
Research Information
The data in this section was derived from dispatch and records management systems provided by the National City Fire Department (NCFD). It covers the period from January 1, 2020, through December 31, 2024, and includes records for all call types across the National City Fire Department service area. This report's analysis is limited to incidents occurring within National City’s jurisdiction, primarily focusing on cases where ambulances were dispatched and arrived on scene.
Statistics Discussion
Mathematical and technological methods must be applied carefully when evaluating a complex system like emergency incident response. Incorrect analyses can have serious consequences, so agencies should combine sound data analytics with professional judgment when making operational decisions. This analysis is intended to quantify and interpret available information, providing a foundation for the agency to use as it seeks to enhance performance or modify services.
Statistical Tools
Various statistical tools were used to develop this section, primarily categorization, percentiles, and regression analysis. These methods provide insight into historical performance and offer inferences that can help leaders identify strengths and areas for improvement.
90th percentile
Time performance in this report is measured using the 90th percentile. While the detailed mathematics behind this metric are beyond the scope of this report, understanding its purpose is important.
EMS Transportation & Optimization Study National City Fire Department
30 The 90th percentile is widely adopted in the fire service and EMS industries, allowing agencies to benchmark performance against standards or peer organizations. For instance, the National Fire Protection Association (NFPA) incorporates this measure in most of its standards, and the Commission on Fire Accreditation International (CFAI) requires performance reporting at the 90th percentile.
Statistically, the 90th percentile provides a more accurate reflection of overall performance, particularly for skewed emergency response data, where other measures may be less sensitive. The following figure illustrates a typical example of data skew.
Figure 10: Data Skew
1 In a symmetric distribution, the mean (average), median (middle value), and mode (most frequent value) are all equal. When a distribution is skewed, these measures diverge. Using the mean in a left-skewed dataset can understate typical performance, while in a right-skewed dataset, it can overstate it. Most time-performance data for National City Fire Department is right-skewed, meaning that relying on the average would exaggerate performance.
Data Engineering Findings
Data Sources and Preparation
National City Fire Department provided four datasets covering the five years from January 1, 2020, through December 31, 2024. These tables contained information from the Records Management System (RMS), Computer-Aided Dispatch system (CAD), and electronic patient care records (ePCR). Upon review, the CAD records were excluded from analysis because they largely duplicated information already captured in the RMS.
1 This Photo by Unknown Author is licensed under CC BY-SA-NC, creativecommons.org/licenses/by-nc- sa/3.0/
EMS Transportation & Optimization Study National City Fire Department
31 The remaining data were enhanced by integrating Geographic Information Systems (GIS) data and expanding CAD code definitions. The datasets were tested and standardized for consistency, and duplicate records were removed. The final dataset included 36,907 incidents and 12,477 apparatus records. Data loss due to processing and integration was negligible, accounting for less than 0.1% of the original records.
Data Error Handling
Data from emergency response systems are prone to errors, typically arising from human entry or system collection issues. Common error-management approaches include statistical exclusion, real-time exclusion, formula adjustments, and logic-based testing.
In the National City Fire Department records, error-prone fields were minimal, requiring little statistical correction. Some data were excluded using formulas and logic checks.
For example, negative or null time segments were removed using a logic tree. Outliers were defined as travel times exceeding 30 minutes and total times exceeding one hour. These criteria still preserved 99% of the records for analysis.
System Demand & Performance
The first aspect of the analysis examines the overall system call volume. Since this involves a straightforward count of ambulance incidents by type and location, no data was excluded during processing.
City Overview
The city’s population density is classified as urban throughout. To make large datasets more manageable, it is useful to organize information into smaller groupings. In this analysis, the most meaningful grouping was by first-due company area.
EMS Transportation & Optimization Study National City Fire Department
32 Incident Volume
Examining overall incident density provides valuable insight into the volume of activity within the system. The following figure illustrates the number of ambulances arriving on scene for all incidents during the study period.
Figure 11: Overall EMS Incident Density (2020–2024)
The two most active pockets are around Station 33 and east of Station 34.
Ambulances are deployed for more than just EMS calls; they may also respond to fires, hazardous materials incidents, and other emergencies. Analysis of the incident data shows that not every dispatched ambulance arrives on scene, and not every arrival results in a patient transport. The following figure summarizes total citywide incidents by type.
EMS Transportation & Optimization Study National City Fire Department
33 Figure 12: Ambulance Assigned Incidents (2021–2024)
Incident Type Count Percent
300—Rescue, EMS incident, other 5 0.02%
311—Medical assist, assist EMS crew 9 0.04%
320—Emergency medical service incident, other 3 0.01%
321—Medical Aid 21,239 90.68%
322—Traffic Accident 2,036 8.69%
323—Motor vehicle/pedestrian accident (MV Ped) 22 0.09% 324—Motor vehicle accident with no injuries. 20 0.09%
331—Lock-in (if lock out, use 511 ) 5 0.02%
350—Extrication, rescue, other 3 0.01%
351—Extrication of victim(s) from building/structure 1 0.00% 352—Extrication of victim(s) from vehicle 5 0.02%
353—Elevator Rescue 59 0.25%
354—Trench/below-grade rescue 3 0.01%
356—High-angle rescue 3 0.01%
360—Water & ice-related rescue, other 2 0.01%
363—Swift water rescue 6 0.03%
During the study period, certain locations experienced multiple ambulance requests.
These high-demand areas can place significant strain on available resources. However, accurately identifying these frequent call locations enables agencies to implement targeted preventative strategies. Understanding where incidents repeatedly occur allows for more efficient allocation of resources and focused prevention efforts. The following figure presents the top ten addresses based on incident frequency, along with the corresponding number of incidents at each location.
EMS Transportation & Optimization Study National City Fire Department
34 Figure 13: Top 10 Addresses (2021–2024)
Top 10 Addresses Count of
Incident #
1200 Highland Ave, NATIONAL CITY, CA/WALMART
Highland Ave & E Plaza BLVD 269
1200 National City Blvd,
NATIONAL CITY, CA/NATIONAL CITY PD HQ 220
1305 E 26th St,
NATIONAL CITY, CA 183
2400 E 04th St,
NATIONAL CITY, CA/PARADISE VALLEY HOSPITAL 103
303 W 26th St, NATIONAL CITY, CA/
FRESENIUS KIDNEY CARE National City 165
3030 Plaza Bonita Rd,
NATIONAL CITY, CA/PLAZA BONITA 161
506 W 22nd St, NATIONAL CITY, CA/
TROLLEY 24th Street - National City 261
555 W 08th St, NATIONAL CITY, CA/
TROLLEY 8th Street - National City 178
735 Arcadia Ave, NATIONAL CITY, CA/
PARKVIEW MEMORY CARE at Paradise Village 98
I-805 SB, NATIONAL CITY, CA/
SB 805 NO PLAZA BLVD 97
Grand Total 1,735
Temporal Analysis
Understanding the temporal elements of incident volume is helpful for leaders to visualize. This allows them to plan for activities other than incidental, such as training, prevention, rest, and public events. Recognizing incident levels by month, day, and hour directly affects deployment. Visualizing annual trends may also help leadership understand the need to change the level of service. The following figure shows the total number of incidents within the city annually.
EMS Transportation & Optimization Study National City Fire Department
35 Figure 14: Annual Incident Volume (2020–2024)
The preceding figure shows consistent annual EMS incidents from 2020 to 2024. Overall volume increased by 6.7% over the past five years.
Monthly fluctuations are minor, generally within ±1% of expected levels. There is a slight uptick in incidents during December and January, but these variations largely reflect the differing number of days in each month. The overall pattern suggests minimal seasonality in National City Fire Department’s incident volume. The following figure illustrates the monthly percentage distribution of incidents across the study period.
Figure 15: Monthly Incident Demand Variation (2020–2024)
6,993
7,626
7,659
7,202
7,427
592
673
625
552
542
563
514
672
661
722
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
2020 2021 2022 2023 2024
EMS FIRE OTHER
4,166
3,451
3,705
3,519
3,422
2,950
3,072
3,175
3,102
3,048
3,037
3,378
331
281
267
262
268
235
283
229
238
263
247
289
372
314
276
256
320
231
260
274
250
298
285
285
-
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
EMS FIRE OTHER
EMS Transportation & Optimization Study National City Fire Department
36 Daily variation is slight and less than +/- 1% expected. Sunday shows the most significant deviation from the expected, at 11%. The following figure shows the percentage of incidents that happen on weekdays.
Figure 16: Variation by Weekday (2020–2024)
There is a more pronounced variation when examining incidents by hour of the day.
Incident activity is not evenly distributed throughout the day; daytime hours are consistently busier than evening, night, and early morning periods. This pattern is likely driven by typical human activity, as people are awake and active during the day. For the National City Fire Department, over 63.7% of all incidents occur between 8:00 AM and 8:00 PM. The following two figures show the EMS incident during the day and night. 5,304
5,902
5,800
5,848
5,781
5,752
5,638
462
512
419
426
462
464
448
398
504
503
542
517
513
444
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
EMS FIRE OTHER
EMS Transportation & Optimization Study National City Fire Department
37 Figure 17: EMS Hotspot Counts DAYTIME (2020–2024)
EMS Transportation & Optimization Study National City Fire Department
38 Figure 18: EMS Hotspot Counts NIGHTTIME (2020–2024)
The preceding analysis shows a clear required surge capacity during the daytime hours. Although the volume is less at night, it is within the response area of stations 33 and 34. The following figure illustrates the percentage of incidents by hour of occurrence.
EMS Transportation & Optimization Study National City Fire Department
39 Figure 19: Incident Volume Percent by Hour (2020–2024)
This curve mirrors the pattern observed in many other fire and EMS systems. Incident frequency rises in the early morning, peaks in the early afternoon, and tapers off during the evening.
Analyzing incident volumes by both weekday and hour provides valuable insight. Some systems exhibit a typical weekday pattern but experience a shift on weekends. In the National City Fire Department system, weekday patterns remain relatively consistent.
However, the system has a higher volume until 19:00. The following figure illustrates incident volumes by hour and weekday across the study period.
00:00
00:30
01:00
01:30
02:00
02:30
03:00
03:30
04:00
04:30
05:00
05:30
06:00
06:30
-
200
400
600
800
1,000
1,200
1,400
1,600
1,800
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Incident Count
Hour of the Day
Incidents Travel
EMS Transportation & Optimization Study National City Fire Department
40 Figure 20: Incident Demand by Hour and Day (2020–2024) DEPARTMENT National City Fire Department
AVAILABLE
STATIONS 3
HOUR↓DAY→ SUN MON TUE WED THU FRI SAT
0 47 38 36 36 40 35 38
1 42 32 36 29 37 31 41
2 34 31 31 24 30 31 36
3 31 24 26 27 22 27 27
4 30 22 24 22 28 28 28
5 28 29 31 29 26 26 25
6 32 40 40 41 33 37 37
7 39 51 45 55 49 41 43
8 47 63 68 64 55 61 52
9 49 77 71 61 68 68 58
10 61 73 74 76 76 63 67
11 64 80 74 83 71 74 69
12 59 79 71 77 83 78 74
13 62 69 75 75 81 77 70
14 61 80 83 77 78 80 73
15 65 76 73 79 77 77 73
16 71 78 79 78 80 72 70
17 67 77 71 76 78 77 72
18 70 79 66 72 70 73 71
19 66 72 66 62 64 73 68
20 61 64 55 68 62 65 58
21 56 55 53 59 53 52 53
22 48 49 54 50 49 49 51
23 47 46 47 46 43 54 54
A final component of the temporal analysis examines the occurrence of simultaneous incidents, also known as concurrency. Understanding concurrency is critical for determining the number of units required at any given time. To maintain data integrity, incidents lasting longer than 12 hours were excluded, representing less than 0.1% of the dataset.
For the National City Fire Department, up to three incidents commonly occur at the same time, with a single active incident being the most frequent scenario. Situations requiring more than four ambulances are rare, occurring in less than 1.37% of all incidents. The following figure illustrates the total number of incidents in progress and the distribution of concurrent incidents throughout the study period.
EMS Transportation & Optimization Study National City Fire Department
41 Figure 21: Concurrent Incidents Totality (2020–2024) Concurrent Units
on EMS incidents Count Percent Cumulative
Percent
1 71,804 92.27% 92.27%
2 3,490 4.48% 96.76%
3 1,372 1.76% 98.52%
4 627 0.81% 99.33%
5 277 0.36% 99.68%
6 125 0.16% 99.84%
7 60 0.08% 99.92%
8 24 0.03% 99.95%
9 14 0.02% 99.97%
10 15 0.02% 99.99%
11 8 0.01% 100.00%
The following figure shows the percentage of concurrency each year from 2020 to 2024. There is a consistent increase each year for concurrent incidents., supporting the need for four and five transport units during peak volume.
Figure 22: Concurrent Incidents by Year (2020–2024)
No. of Units 2020 2021 2022 2023 2024
Single Unit 0.25% 25.96% 34.61% 41.54% 32.45%
Two Units 0.22% 24.17% 21.21% 18.26% 22.71%
Three Units 0.15% 19.10% 17.51% 15.20% 17.21%
Four Units 0.14% 12.40% 9.85% 10.41% 11.55%
Five Units 4.10% 7.35% 3.44% 5.90% 6.46%
Six Units 0.00% 4.23% 0.00% 3.25% 3.67%
Seven Units 2.34% 2.51% 0.00% 1.81% 2.20%
Eight or More Units 4.10% 4.30% 13.39% 3.63% 3.76%
Unit Volume
A comprehensive assessment of each unit is beyond the scope of this report.
Nevertheless, it is useful to understand the average time each apparatus spends on different types of incidents. The following figure presents the average number of minutes each unit type is engaged by incident.
EMS Transportation & Optimization Study National City Fire Department
42 Figure 23: NCFD Average Unit Type Commit Time by Incident Category (2020–2024) Unit 2020 2021 2022 2023 2024 Average
UHU
B57 10.02% 7.69% 6.56% 5.39% 5.34% 7.00%
NCE234 2.81% 0.02% 0.13% 0.15% 0.95% 0.81%
NCE31 16.82% 16.04% 19.15% 16.90% 17.30% 17.24%
NCE34 26.40% 30.65% 34.66% 30.79% 24.17% 29.33%
NCSQ33 22.90% 25.80% 27.32% 27.97% 21.58% 25.11%
NCT34 6.50% 8.24% 8.16% 8.72% 7.44% 7.81%
Figure 24: AMR Average Unit Type Commit Time by Incident Category (2020–2024) Unit 2020 2021 2022 2023 2024 Grand
Total
AM254 57 141 135 151 108 592
AM255 36 110 98 75 90 409
AM256 29 118 94 55 93 389
AM257 131 191 247 258 261 1,089
AM411 204 47 - - - 251
AM412 220 150 59 27 38 494
AM413 184 47 - - 0 231
AM414 398 99 1 1 - 499
AM415 356 108 1 1 - 466
AM416 637 510 449 450 565 2,611
AM417 2,207 2,805 3,719 3,440 2,816 14,987
AM418 1,911 2,551 3,310 2,719 2,743 13,234
AM420 284 100 - - - 384
AM492 52 93 99 53 52 349
AM493 176 41 6 - - 223
AM494 13 7 9 - - 29
Total 6,895 7,118 8,227 7,230 6,766 36,236
The objective of this analysis is to determine the number of ambulances required for the system. A clear understanding of the distinction between commit time and unit hour utilization (UHU) is essential for accurately evaluating staffing needs. Since each ambulance is typically committed to an incident for an average of 55 minutes, it may not be immediately available for additional calls during that period.
EMS Transportation & Optimization Study National City Fire Department
43 Unit hour utilization represents the proportion of time a unit is actively engaged on incident scenes relative to the total hours it is available. This metric is commonly expressed as a percentage or a decimal. For example, a 24-hour ambulance is staffed for 8,760 hours per year. If that unit is committed to incidents for 2,628 hours annually, its UHU would be 30% (or 0.30).
𝑈𝐻𝑈 =
∑ 𝑇𝑖𝑚𝑒 𝐶𝑜𝑚𝑚𝑖𝑡𝑒𝑑 𝑡𝑜 𝑎 𝑆𝑐𝑒𝑛𝑒
∑ 𝑇𝑖𝑚𝑒 𝑈𝑛𝑖𝑡 𝑖𝑠 𝑆𝑡𝑎𝑓𝑓𝑒𝑑 𝑎𝑛𝑑 𝐼𝑛 𝑆𝑒𝑟𝑣𝑖𝑐𝑒
In a system where units move directly from one incident to the next without interruption, the unit hour utilization (UHU) would theoretically be 100%. While this represents maximum efficiency and profitability, it is unrealistic for most operations. Crews require downtime, and incidents rarely occur in a perfectly continuous manner.
For-profit ambulance providers often use UHU targets to assess the profitability of a region, market, or specific unit. While these targets vary by company and operational strategy, studies, such as one conducted by the Academy of International Mobile Healthcare Integration, indicate that members typically achieve UHU values between
22.8% and 47.6%. However, the upper end of this range is generally impractical for most public agencies, particularly those operating 24-hour shifts.
Public agencies should adopt a UHU that balances community service demands with crew obligations. A 24-hour unit has scheduled activities built into each shift, including rest, meals, training, and physical fitness. Rest alone may account for 6–8 hours, while the combination of training, meals, and fitness can take an additional 6 hours, totaling nearly 58% of the shift. This leaves only 42% of a 24-hour period available for incident response.
Sustaining operations consistently at the 33% UHU level would reduce reliability and leave little system resiliency. Therefore, for this report, an optimal UHU of 35% will be assumed, providing adequate coverage while allowing for necessary crew duties and maintaining system flexibility.
EMS Transportation & Optimization Study National City Fire Department
44 Understanding the average number of units needed per day, the typical time each unit is committed to an incident, and the projected UHU allows for estimation of the average number of units required. This is calculated by multiplying the average unit demand by the UHU. Fractional unit results are rounded up to determine the number of full ambulances needed during each hour. The following figure illustrates the total number of units required within the National City Fire Department system based on these averages.
Figure 25: Predicted Total Number of Units Needed by Hour and Day (2024) DEPARTMENT National City EMS
Unit Hours
Needed
HOUR↓DAY→ Sun Mon Tue Wed Thu Fri Sat
0 3 2 2 2 2 2 2
1 2 2 2 2 2 2 3
2 2 2 2 1 2 2 2
3 2 1 2 2 1 2 2
4 2 1 2 1 2 2 2
5 2 2 2 2 2 1 1
6 2 2 2 2 2 2 2
7 2 3 2 3 3 2 2
8 3 3 4 4 3 4 3
9 3 4 4 3 4 4 3
10 3 4 4 4 4 3 3
11 3 4 4 5 4 4 4
12 3 4 4 4 4 4 4
13 3 4 4 4 4 4 4
14 3 5 4 4 4 4 4
15 3 4 4 4 4 4 4
16 4 4 4 4 4 4 4
17 3 4 4 4 4 4 4
18 3 4 4 4 4 4 4
19 4 4 3 3 3 4 4
20 3 3 3 4 3 4 3
21 3 3 3 3 3 3 3
22 3 3 3 3 3 3 3
23 3 3 3 3 2 3 3
EMS Transportation & Optimization Study National City Fire Department
45 GIS Modeling
For context, three travel time benchmarks were evaluated using GIS modeling. The first is the NFPA travel time standard of 4 minutes, as defined in NFPA 1710: Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments.
Figure 26: 4-Minute Drive Time
Beyond the standard NFPA travel time benchmark, there may be operational reasons to position an ambulance at any of these facilities. Whether managed by the city or a third-party provider, these stations offer strong coverage for densely populated areas but provide more limited coverage in remote and wilderness regions. The following figure illustrates the urban coverage areas for 8-minute performance goals.
EMS Transportation & Optimization Study National City Fire Department
46 Figure 27: 8-Minute Drive Time
The station locations across the city provide strong overall coverage and favorable theoretical response travel times.
Response Performance
In analyzing response performance, AP Triton employs percentile measurements to assess response time performance. These measurements are derived from industry best practices outlined by the Center for Public Safety Excellence (CPSE) and the National Fire Protection Association (NFPA) standards 1710: Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments and NFPA 1720: Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Volunteer Fire Departments. Percentile measurements offer a more accurate representation of performance as they consider the performance of most data points, reducing the impact of outliers.
EMS Transportation & Optimization Study National City Fire Department
47 The “average” measure is a commonly used descriptive statistic called the mean of a data set. 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.
The “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 90 th
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 fractile 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 interval between the time the alarm is received at the primary 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 interval between the time that personnel or units are notified of a call and the time when they begin to respond to the incident. • Travel Time: The time interval begins when a unit is en route 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 utilized measure of fire department response performance. • Total Response Time: The NFPA 1710/NFPA 1720 definition of Total Response Time is “the 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 the time between receiving the alarm at the dispatch center and the arrival of the first fire department unit.
EMS Transportation & Optimization Study National City Fire Department
48 Figure 28: Response Time Continuum
The definitions for each population category follow the Center for Public Safety Excellence (CPSE) 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).
The following sections look at three perspectives. First, the performance of the fire department at the 90
th percentile. The second looks at all ambulances, including neighboring agencies and AMR. The third perspective focuses on the performance of AMR alone.
Alarm Processing Time
The following figure shows the alarm processing time performed by Dispatch. After removing outliers, the Dispatch Center appears to have opportunities for improvement since the processing time exceeds national NFPA standards.
Figure 29: Alarm Processing Time Performance (2019–2021)
03:04 03:23 03:04 03:22
00:00
00:30
01:00
01:30
02:00
02:30
03:00
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EMS Transportation & Optimization Study National City Fire Department
49 Turnout Time Performance
The ability to quickly react to the notice of an alarm and begin responding to an incident is the first component under the direct control of the fire department and EMS personnel. Turnout time is the time it takes personnel to receive the dispatch information, move to the appropriate apparatus, and proceed to the incident.
NFPA 1710 specifies that turnout time performance for staffed stations should be less than 60 seconds, measured at the 90th percentile for incidents other than fire and special operations. For those incidents, turnout time performance should be 1 minute, 20 seconds. There is no specific performance specified for non-staffed stations.
Figure 30: NCFD System Turnout Time Performance (2020–2024)
As illustrated in the preceding figure, the turnout time for NCFD during the study period also exceeded industry standards.
Travel Time Performance
Often, travel time is the most extended segment of the total response time. This may be impacted significantly by geographic location, traffic, time of day, weather, and other factors.
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EMS Transportation & Optimization Study National City Fire Department
50 Figure 31: NCFD EMS System Travel Time Performance (2020–2024)
As illustrated in the preceding figure, the travel time performance is close to industry standards and supports the current station locations.
Response Time Performance
When turnout and travel time are combined, this is expressed as response time with an expected performance of five minutes or less in a staffed station. This is one of the most often tracked and reported response time performance measures, comprising components under the Department's direct control.
Figure 32: NCFD EMS Response Time Performance (2020–2024)
As previously stated, NCFD has reached service demand capacity, and future growth will require additional resources to maintain response performance benchmarks.
The final metric looks at the combined time of all performance metrics and represents the total time a citizen waits for a response from the moment they place a 911 call to the arrival of resources.
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EMS Transportation & Optimization Study National City Fire Department
51 Figure 33: NCFD EMS Total Response Time Performance (2020–2024)
The preceding analysis demonstrates an opportunity for overall system improvement.
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EMS Transportation & Optimization Study National City Fire Department
52 POPULATION GROWTH & SERVICE
DEMAND PROJECTIONS
Service demand is largely driven by population—without residents, the need for emergency services is minimal. The relationship between total population, population density, growth trends, and incident volume is complex and not fully understood.
Nevertheless, applying regression analysis and forecasting tools can provide leadership with sufficient insight to make informed decisions regarding resource allocation and deployment.
Population Growth
The population in National City decreased from 58,582 in 2010 to 56,173 in 2020—a decline of 2,409 people or approximately 4.1%. This contrasts with the national growth rate of 7.18% and California's growth rate of 5.90% during the same period. The most significant single-year decrease occurred between 2019 and 2020, with a drop of 5,094 people (8.31%).
2020–2023
The decline continued post-2020, with the population falling to an estimated 55,236 by the end of 2023, a decrease of 977 people (1.74%) from 2020. This included a drop of 25 people between 2021 and 2022 and 533 people (0.96%) between 2022 and 2023. Over the 2013–2023 period, the population decreased by 4,593 (7.68%), with an average annual growth rate of -0.76%.
Peak and Low Points
The population peaked in 2017 at 61,560 and reached its lowest point in 2023 at 55,236.
Between 2000 and 2023, the population grew by 1,110 overall, but the trend since 2017 indicates a consistent decline.
Factors Influencing Population Changes
Economic and Social Factors
National City’s median household income in 2023 was $64,248, below the California state average, with a poverty rate of 13.97% (higher than the state average of 12.4%).
These economic challenges may contribute to out-migration.
EMS Transportation & Optimization Study National City Fire Department
53 Demographic Composition
The city has a diverse population, with 65.8% Hispanic, 16.8% Asian, and 9.5% White residents in 2023. A significant portion (36.9%) of residents are foreign-born, which may influence migration patterns due to changes in immigration policies or economic opportunities.
Regional Context
California as a whole has seen a population decline since 2020, dropping from 39.52 million to 39.43 million by 2024, driven by lower birth rates, aging populations, and net out-migration, particularly in coastal counties. National City’s trends align with this broader state pattern, though its proximity to San Diego and the Mexican border may create unique dynamics.
Projected Population Trends (2024–2040)
Specific projections for National City’s population through 2040 are limited by the available data. Still, we can infer trends based on historical patterns and broader state projections:
Short-Term Projection (2024–2025)
One source estimates National City’s population in 2025 to be 54,584, assuming a continued annual decline of -0.59%. However, another source projects a population of 65,464 by 2025, based on a 2010–2014 growth rate of +0.74% per year. This discrepancy highlights uncertainty, as the recent trend of decline (-0.683% from 2022 to 2023) suggests the lower estimate is more likely unless significant changes occur.
Long-Term Projection (2030–2040)
No direct projections for National City extend to 2040, but California’s population is expected to grow modestly, reaching 50 million by 2050 with a low annual growth rate of about 1%. Growth is projected to be stronger in inland regions like the Inland Empire and San Joaquin Valley, while coastal areas like San Diego County may see slower growth or declines due to high living costs and out-migration. National City, as a coastal city, may continue to experience stagnation or slight declines unless economic or policy changes (e.g., increased immigration or local development) reverse the trend.
EMS Transportation & Optimization Study National City Fire Department
54 Uncertainty and Variables
Projections are uncertain due to fluctuating migration patterns, economic conditions, and demographic shifts. For instance, lower immigration and an aging population (California’s median age is rising, with 25% of residents projected to be over 60 by 2031) could further depress National City’s growth. Conversely, its proximity to San Diego’s economic hub and Naval Base San Diego could stabilize or boost population if development projects (e.g., Southwestern College expansion or Kimball Park) attract residents.
National City is classified as an urban, incorporated city. This study utilized historical population data and projections provided by the California Department of Finance (CDOF). The CDOF publishes annual population estimates for each county and incorporated city, drawing from the U.S. Census Bureau and state records, with city- level data from 2010.
The incorporated area of National City covers 10.07 square miles, and the 2023 CDOF population estimate was 55,236. The following figure illustrates the 17-year estimated population growth from 2010 through 2023 based on the CDOF annual estimates.
Figure 34: 17-Year Population Forecast with 95% Confidence Bands
Based on the historical population estimates, the population is expected to remain relatively stable. Using this forecasting approach, the projected population in 2040 is
estimated to be approximately 50,224 with a 95% confidence level. 61,600
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EMS Transportation & Optimization Study National City Fire Department
55 Population Distribution
National City is a densely populated city with the highest population in the center of town. The following figure shows the population density distribution for the National City.
Figure 35: 2023 Population Distribution
Service Demand
A standard linear forecast accounting for potential seasonality was used for this analysis. While future service demand cannot be predicted with certainty, examining the previous five years of data—while smoothing the effects of the 2020 pandemic— provides a reasonable estimate of incident growth. For the National City Fire Department, projected growth is modest. The model estimates ambulance runs in 2040 to range between 5,431 and 5,536, with a 95% confidence interval.
The following figure illustrates the projected ambulance service demand based on data from the prior five years.
EMS Transportation & Optimization Study National City Fire Department
56 Figure 36: Service Demand Projection to 2041
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EMS Transportation & Optimization Study National City Fire Department
57 SECTION II:
EMS SYSTEM VALUATION
EMS Transportation & Optimization Study National City Fire Department
58 FINANCIAL ANALYSIS OF EMS
TRANSPORT SERVICES
Understanding Health Care Financing
Healthcare financing can feel more like a maze than a map, especially for city and county leaders already juggling budgets, labor contracts, and public-safety programs.
At its core, money flows from four main directions: federal payers such as Medicare and the Department of Veterans Affairs (VA), state programs like Medicaid or California’s Medi-Cal, commercial insurers, and patients themselves. Every other label, secondary coverage, workers’ compensation, auto and travel plans, ACA exchanges, co-pays, deductibles, simply adjusts who pays first, how much is paid, and when the bill finally reaches a resident.
For any local agency that runs an ambulance service or community clinic, the first figure to grasp is its payer mix: the percentage of encounters in each of those four buckets. Medicare rates are fixed by Congress. Medi-Cal pays less but may offer supplemental pools such as GEMT or QAF. Commercial contracts can be negotiated.
Self-pay accounts often turn into bad debt. Understanding this mix lets administrators build a realistic revenue model and see where policy changes, such as an increase in Medi-Cal managed-care enrollment or a new Covered California plan, could tighten or boost cash flow.
The next focus is on documentation and billing accuracy. Federal payers will deny a claim for a missing oxygen saturation just as quickly as a private insurer. Detailed run sheets, ICD-10 codes that match the
clinical picture, and prompt
electronic submission shorten the
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EMS Transportation & Optimization Study National City Fire Department
59 Local governments have levers that larger health systems do not. Intergovernmental transfers and certified public expenditures can draw additional federal matching dollars for ambulance transports and public health clinics. Grants tied to opioid settlement funds, or 1115 waiver projects, can support community paramedicine pilots that reduce uncompensated care at area hospitals. These programs are paperwork- heavy, but a modest investment in grant management or a shared-services agreement with neighboring jurisdictions often pays for itself.
Finally, establish a cross-functional finance team that meets monthly. Include the finance director, EMS chief, legal counsel, and any contracted billing vendor. Track payer-mix shifts, denial rates, days in accounts receivable, and write-offs. Pair those metrics with a policy watch list that flags changes to Medi-Cal managed-care capitation, ACA subsidy adjustments, or upcoming labor cost increases. With clear data, disciplined billing practices, and targeted supplemental funding, even the complex world of healthcare financing can become a manageable and predictable part of a local government budget.
Determining the Value of the System
Numerous factors impact the value of an EMS 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 secret methods for collecting payments from an EMS system. A fixed amount of money is available to all providers, whether public or private; this is often referred to as the revenue cap. However, disparities exist in revenue collection among various providers due to two main areas: billing and collections.
Some agencies are more effective at securing funds in these areas than others.
EMS Transportation & Optimization Study National City Fire Department
60 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 financial management. Key factors affecting billing and collections success include:
• Billing Policy
• Collection Rate
• Transport Rates
• Documentation
• Billing Collector's Level of Effort
• Number of Transports
• Payer Mix
The value of National City’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
• Documentation
• Billing Collector's Level of Effort
However, certain elements are beyond the City's direct control:
• Number of Transports
• Payer Mix
EMS Transportation & Optimization Study National City Fire Department
61 Billing Policy
Establishing a billing policy is a crucial step for providers to maximize revenue from the healthcare system. Several factors must be considered when developing a billing policy, including how aggressive the billing approach will be. A more aggressive policy increases collection potential, but fixed rates in various areas cap the maximum possible collections. Additionally, the number of service calls remains relatively stable; increasing ambulance availability does not necessarily lead to more transports. The expectation is that all patients requiring transport will receive it, and while call volumes fluctuate, significant or seasonal changes are predictable. American Medical Response currently does all the billing for the city. The contract between the City and AMR establishes an ALS pass-through fee, which is a set rate established to be paid to the City. This fee will need to be added to the overall compensation in the system to compare the current model with any future models.
Understanding that the billing policy established by a private provider, or the city if it chooses to develop one, will heavily impact the residents of National City. By carefully crafting and implementing a comprehensive billing policy that incorporates these factors, providers can enhance revenue streams and ensure the sustainability of their EMS services.
Collection Policy
The collection policy is a crucial aspect of the billing process, significantly impacting revenue. Federal regulations require that every patient receive a bill for services rendered, preventing selective billing practices where only certain patient groups are targeted. A company's aggressiveness in its collection efforts often reflects its business philosophy. Most private ambulance companies and hospitals implement aggressive collection policies, while many public ambulance providers opt for less stringent approaches.
The reason for this difference is straightforward: private ambulance companies are focused on generating revenue or profit. Sending patients to collections or placing them on strict payment plans is standard practice for these companies. In contrast, public sector providers must consider the political and public relations implications, as their patients are taxpayers.
A practical guideline for collections is that the process should continue if the financial or political return justifies the effort. It should cease when further collection efforts' costs or potential negative consequences outweigh the potential monetary gain.
EMS Transportation & Optimization Study National City Fire Department
62 Balancing effective revenue collection with public accountability and sensitivity is essential for public ambulance providers. A well-considered collection policy can help achieve this balance, ensuring financial sustainability while maintaining public trust.
Transport Rate
Setting an appropriate transport rate is crucial for ensuring financial sustainability while maintaining fairness and regulatory compliance. Every patient is charged a transport fee, regardless of insurance status or ability to pay, making consistency in billing essential.
Transport revenue is directly tied to the percentage of transports relative to total responses. While increased transports generate more revenue, transporting every patient is not always practical due to the overcrowded healthcare system. National City, as a public provider, does not need to generate profits like private companies but must ensure long-term financial stability while prioritizing patient care.
Non-transport decisions have significant financial implications. If two ambulances each record one non-transport per shift, the city loses 730 billable transports annually. At Medicare’s base rate of $522 per transport, this results in over $380,000 in lost revenue per year. While transports should not be the goal in the system, it is helpful to understand that their impact can be estimated and managed as a percentage of total call volume.
Cost recovery is necessary for system efficiency, but should not override clinical judgment. Transport decisions should always prioritize patient well-being to maintain public trust and transparency. Making financial considerations a primary factor in transport decisions could damage credibility and erode confidence in the service.
Emergency transport fees vary by payer. The following figure outlines allowable charges by Medicare and Medi-Cal:
EMS Transportation & Optimization Study National City Fire Department
63 Figure 37: Medicare and Medi-Cal 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 $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 the PP-GEMT payments.
While Medicare and Medi-Cal place limits on reimbursement, National City should not be constrained by these figures when setting transport rates. Expanding chargeable services and adjusting rates can improve cost recovery. Additionally, private and commercial insurance, covering an estimated 22% of transports, 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. Errors in documentation can lead to lower reimbursement rates, such as billing an Advanced Life Support (ALS) service at the lower Basic Life Support (BLS) rate. Proper documentation can significantly increase revenue where ALS services are provided.
For instance, with an average cost recovery of $500–$1,000 per transport, preventing just one daily denial due to improper documentation could generate an additional $180,000 to $360,000 annually, enough to fund at least one full-time paramedic.
EMS Transportation & Optimization Study National City Fire Department
64 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. National City relies on its billing agency for feedback and follows San Diego County’s EMS policy S-601, Documentation Standards and Transferal of Prehospital Care Records (PCR) Information, to maintain high standards. Common documentation deficiencies that can delay reimbursement include:
• 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. National City must continue refining its compliance program to leverage ePCR advancements effectively.
Billing Contractor's Level of Effort
Ambulance billing contractors play a crucial role in EMS revenue cycle management.
Clearly defining contractor expectations ensures efficient and accurate billing processes.
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. When a city contracts with a third-party billing company, associated expenses should be factored into 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.
EMS Transportation & Optimization Study National City Fire Department
65 Establishing clear expectations for billing contractors is essential to municipal EMS financial sustainability. A well-defined policy outlining service scope, timelines, and accuracy requirements fosters an effective partnership between contractors and EMS providers, maximizing revenue potential.
Understanding the Payer Mix
Demographics of the Healthcare Payer Mix
The sustainability of the healthcare system is largely dependent on the payer mix within a given geographic area. In the Emergency Transportation System, payer mix and transport volume directly influence financial viability. Understanding how payer 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 generally achieve higher cost recovery rates than one with a large uninsured population.
Additional reimbursement subcategories, such as workers’ compensation, liability, and auto insurance, exist within these primary categories but are not covered in this report.
Medicare
Medicare typically constitutes the largest segment of a system’s payer mix since it covers all individuals over 65. In National City, Medicare accounts for an estimated 45% of transported patients.
EMS Transportation & Optimization Study National City Fire Department
66 Medicare imposes a billing cap, currently set at just over $650.00. It reimburses 80% of the allowed amount, equating to approximately $521.60, with an additional co-pay recoverable at an estimated 30% success rate. For a system with an average service charge of $2,000, Medicare’s reimbursement remains $521.60 (plus mileage), while the patient’s co-pay is an estimated $130.00.
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 payer mix and the protections that prevent Medicare recipients from being affected by rate increases.
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 Medicare and Medi-Cal, which is referred to as “Medi-Medi.” Like Medicare, Medi-Cal has a payment cap, currently set at approximately $118.00, 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 third-largest payer mix among transported patients in National City, comprising approximately 33% of the total transports.
Commercial Insurance/Private Insurance
This payer mix category includes individuals with medical insurance obtained through employment, private purchase, or other means. Commercial insurance, also known as private insurance, generally consistently reimburses for ambulance transportation and first response fees, leading to an estimated reimbursement rate of 80%.
Commercial insurers typically cover a usual and customary payment based on billed charges. In National City, the average Advanced Life Support (ALS) transport charge is $4,606, with most commercial insurers reimbursing at least 80%, or approximately $3,685 per transport. Increasing the average charges in the system by as little as 5% could generate significant additional cost recovery in the system.
EMS Transportation & Optimization Study National City Fire Department
67 Private Pay
This payer mix category includes individuals who do not qualify for Medi-Cal, have not applied, or lack commercial insurance. It encompasses a broad economic range, from those with minimal income to those earning above-average wages. Traditionally, this group consisted of individuals employed by small businesses that did not offer insurance or those who were self-employed.
As a result, private pay patients vary widely in their ability to cover ambulance transportation and first responder fees. Some can afford the full cost, others are unable to pay, and some can make partial payments through agreements. Due to this economic diversity, the aggregate reimbursement rate for this group is typically around 5% of total collections.
With the implementation of the Affordable Care Act (ACA) and Covered California, more individuals from this demographic are transitioning into insured categories.
However, the long-term impact on collection rates remains uncertain, as many ACA plans have higher deductibles that may still leave financial gaps.
Payer Mix & Transports
Using information gathered from AMR’s billing report, the payer mix in 2024 for National City was Medicare—43.9%, Medi-Cal—32.4%, Commercial Insurance—6.3%, and Self Pay—14.7%, with 2.5% remaining in the “Other category”. For estimations in this study, the “other category” was distributed evenly to the other columns.
The following figure illustrates the estimated payer mix and transport volume for National City. According to the data received from the city, the estimated medical call volume was 7,184 in 2024, with a total of 5,435 transports, resulting in a call-to-transport rate of approximately 75.65%.
These figures will be used to estimate the system’s call and transport volumes for 2025.
The predicted call volume is based on a 3% increase in volume and transports from 2024. As noted earlier, adjustments to call volume and, more critically, transport volume can significantly impact cost recovery within the system.
EMS Transportation & Optimization Study National City Fire Department
68 Figure 38: Calculated Payer Mix
Cost Center Percent of Transport Number of Transport
Medicare/Medicare HMO 44.53% 2,493
Medi-Cal/Medi-Cal HMO 33.03% 1,849
Commercial Insurance 7.13% 399
Self-Pay 15.33% 857
Total 100% 5,598
Applying the reimbursement formula to the payer mix requires adjustments for collection rates. One method utilizes a simple percentage-to-volume ratio. Variations in collection percentages across the payer mix largely depend on the stability of each cost center.
Medicare is the most stable cost center due to its well-defined eligibility requirements.
Medi-Cal and private 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.
A portion of charges within each category is typically unbillable for various reasons, the most common being lapsed coverage or unmet deductibles.
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EMS Transportation & Optimization Study National City Fire Department
69 To estimate EMS system revenue, the current National City-authorized service rates must be applied. If National City chooses to assume the provider of record for their system, AP Triton recommends conducting a fee study to establish a fee schedule that allows the City to recover costs for providing services in the system. The following figure outlines National City’s current approved transport charges:
Figure 39: Authorized National City Rates for Services
Service ALS Rate BLS Rates
Base Rate $3,845.22 $2,066.00
Oxygen $271.06 $271.06
Mileage $125.00 $125.00
Average Transport Charge $4,605.75 2,826.53
For a total calculation, we will assume the following:
• ALS Transport at 50% of transports
• Oxygen at 50% of transports
• Mileage at 5 miles per transport
The following figure represents the average reimbursement per transport for each payer mix. This table provides the total annual revenue breakdown based on each payer mix, as identified in the data received for this study.
Figure 40: Transportation Reimbursement Calculation
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% $3,685 $230
Self/Private Pay per Transport @ 5% $2,261 $141
Using these standard revenue predictions, the reimbursement from each payer mix can be estimated based on the transports in the system. The following figure outlines these amounts.
EMS Transportation & Optimization Study National City Fire Department
70 Figure 41: Payer Mix Reimbursement
Cost Center Net Collection Amount
Medicare/Medicare HMO $1,249,297
Medi-Cal/Medi-Cal HMO $2,141,368
Commercial Insurance $1,186,611
Self/Private Pay $159,248
Additional 30% Medicare Collection $97,519
Total Estimated Payer Mix Reimbursement $4,834,044
AP Triton believes these calculations follow a standard formula for evaluating a system's available cost recovery. These figures do not include additional revenue from co- pays/deductibles or out-of-pocket expenses from commercial insurance. Should a provider choose to bill for these out-of-pocket expenses, the value of the system could increase.
AP Triton typically sees reimbursements that fall between 25%–35% of the total billed amounts. This uses the realized collection percentages in numerous other departments and agencies across California. Using this calculation, $20,803,138 would have been billed ($4,834,044 ÷ $20,803,138 = 23.24%). Additionally, public ambulance providers benefit from an enhanced Medi-Cal reimbursement of $1,158.10, compared to the QAF reimbursement available to private ambulance providers. Based on the City’s payer mix, the value of the EMS system to a private ambulance transport provider is roughly $900,000 less than the value of the same system to a public transport provider.
EMS Transportation & Optimization Study National City Fire Department
71 RESOURCE NEEDS AND WORKLOAD
ASSESSMENT
Unit Hour Utilization & Time on Task
Unit hour utilization (UHU) 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. In fire-based EMS systems, UHU is a key metric for assessing workload. 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 determine emergency call volume capacity.
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.
Public and private providers measure workload similarly, but there are slight differences in everyday items and how they are measured. For example, public agencies typically add daily training to their workload measurement, whereas the private industry does not typically do training on duty. The private industry might pull units out of service for meal breaks, while the public agencies do not.
The ambulance industry's standard workload measurement is identified as unit hour utilization. Low utilization would indicate a system that could have been more efficient in its deployment. This deployment could make it hard to recover costs from transportation to manage the system. A high UHU may indicate the need for additional unit hours to lower response times and reduce staff fatigue. The UHU measurement has become a national standard; an example would be the City of Sacramento's proposed budget for FY 2022/2023:
EMS Transportation & Optimization Study National City Fire Department
72 The acceptable standard measurement of ambulance usage is UHU. UHU is the ratio of hours spent delivering emergency medical services to the number of hours the medic units are available. For example, a UHU of 0.50 indicates that a team utilized 50% of the total time available throughout the year. A high UHU means lower availability for calls. Poor availability can negatively affect response times.2
Figure 42: Standard Unit Hour Utilization Rates
Unit Hour Utilization UHU Range
0.55–0.45 High Utilization
0.45–0.35 Above Average Utilization
0.35–0.25 Average Utilization
0.25–0.15 Below Average Utilization
0.15–0.01 Low Utilization
A well-designed deployment model allows National City to maximize its resources and cost recovery without overburdening personnel. The following figure illustrates how UHU is developed. In this example, a 24-hour unit has approximately 12.5 hours per day allocated for non-emergency activities, including equipment checks, breaks, training, and rest. This leaves eight hours, or 35% (0.35 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 designed to remain sustainable. UHU is about setting up a sustainable system and not just covering the call load for one day.
2 chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cityofsacramento.org/- /media/Corporate/Files/Finance/Budget/FY2022_23_Proposed-Operating-Budget.pdf?la=en
EMS Transportation & Optimization Study National City Fire Department
73 Figure 43: Determining Adequate TOT 24 hours
Daily Operations Count Count
Hours in the day 24 Hours 12 Hours
Unit/Equipment Maintenance 1 1
Food Breaks 3 2
Fitness/Training 2 1
Sleep 6 0
Other 2 0
Wall Time (APOT) 2 2
Used Hours in Normal Day 16 5.5
Standing TOT 0.66 0.46
Maximum Recommended
UHU 0.35 0.54
Standard TOT/UHU
Firefighter Ambulance .35–.40 .35–.40
Single Role .45–.55 .50–.75
The following figure represents the total responses for each fire unit in National City for medical aid. Using these numbers and the transport volume from AMR is a strong indicator of the impacts on the system. These numbers can also help to understand the UHU in the system.
Figure 44: Number of Incident Responses by Unit (2020–2024) Year Medical Call
Volume
ALS Transport
Volume
BLS Transport
Volume Total Transports
2024 7,184 2,718 2,718 5,436
2025* 7,400 2,799 2,799 5,598
*Total taken from adding 3% to 2024 statistics with 50% for ALS and BLS transports
Using the 2025 projected medical call/transport volume and a standard UHU of 0.35 or 35%, the number of ambulances needed in the system can be estimated.
EMS Transportation & Optimization Study National City Fire Department
74 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 with a heavy call continuance at certain times of the day might indicate the need for 10- or 12-hour units (surge units) to cover busy times while not needing those units on slower times. An example would be needing a surge unit from 8 AM to 6 PM to cover peak activity and not needing a surge unit from 10 PM to 8 AM due to the slowdown of calls overnight.
The following figure takes into consideration call volume, transport volume, and non- transport volume. This, along with call concurrence call volume, helps to portray a complete picture.
Figure 45: UHU/Medical Aid Information
Call/Deployment Information Medical Aid Information
24-Hour Units
Total Medical Aids 7,400
Total Transports 5,598
UHU 0.35
Deployment Hours Required 15,994–21,143
Total Daily Hours Required 43.82–57.93
24-Hour Units Required 2–3 Units
12-Hour Units
Total Non-Transports 1,802
UHU 0.54
Deployment Hours Required 1,112–1,716
Total Daily Hours Required 3.05–4.70
12-Hour Units Required 1 Unit
EMS Transportation & Optimization Study National City Fire Department
75 COSTS OF THE EMS SYSTEM
All ambulance transport delivery models offer diverse benefits and many challenges.
One of the main challenges is the cost of providing the service, and personnel are the most significant part of the cost.
Personnel Costs
Two cost items under personnel will be considered when developing the system's modeling: Salary and Benefits. Typically, these two cost items are known factors that each City or a City’s Human Resource department provides and make up a large portion of the costs when deploying units.
Salary
The salary for personnel in the models described in this report is divided into two distinct categories: sworn and non-sworn.
Sworn
The sworn salaries used are taken directly from the tables filled out for this report. A 15% bonus is added to the Firefighter EMT salary for maintaining a paramedic license. The salary is based on a 56-hour work week and 2,912 hours per year. • EMT Firefighter Salary—$98,690
• PM Firefighter Salary—$111,816
Non-Sworn
The non-sworn salaries use a median salary from the private provider in and around National City. Non-sworn personnel are not exempt from the Fair Labor Standards Act (FLSA), so each model explored accounts for overtime built into the schedule. The salary is based on a 40-hour work week, with anything over 40 paid at a time-and-a-half rate. The schedule is two days on and four days off, which incorporates 2,016 straight- time hours and 824 overtime hours.
• Non-Sworn EMT—$61,788 ($19.00/hr.)
• Non-Sworn PM—$78,048 ($24.00/hr.)
EMS Transportation & Optimization Study National City Fire Department
76 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. The benefits packages used by the models (sworn and non-sworn) are taken from the data provided in this study. The current firefighter benefits package will be used for sworn and non-sworn personnel.
• Yearly Benefits Package—$36,763
Overtime
Overtime can vary depending on the type of personnel (sworn vs non-sworn) evaluated and the amount of leave the city provides. The data shows an average of 116 hours for sick leave, and 213 hours of vacation were used per employee. For the modeling, 192 (eight shifts) yearly paid time off (PTO) will be used for non-sworn, and 213 hours will be used for sworn personnel.
Administrative Costs
The following section deals with administrative overhead costs related to the ambulance transport system. Some of these duties could be absorbed by current personnel; however, for consistency in the report, all positions are listed as independent from current staffing.
Chief Level Supervision
AP Triton typically recommends an Assistant/Deputy/Battalion Chief position responsible for complete system oversight and planning. This section or division will introduce an estimated $4.8 million into the department and manage over 12–16+ new employees, or a contract costing millions. The following sections describe positions that are essential in managing an ambulance transport system. Page 350 of 400 EMS Transportation & Optimization Study National City Fire Department
77 BC Operations Manager/EMS
The EMS Battalion Chiefs (BC) position is responsible for the program’s daily operations, including deployment of resources, required unit hours, response times, and reporting requirements. They monitor dispatch for system status. If sub-contracting, the BC will be the point of contact for contractors' daily staffing, deployment, or response issues. They will also coordinate with contractors’ supervisors for disaster responses, hospital issues, or other significant incidents. The number of ambulances required for National City could also be managed by the existing Battalion Chiefs currently working in the system.
Captain Logistics Coordinator/EMS
The model that National City chooses will depend on the level of overhead staffing needed. If a single-role model is adopted, there will be an increased need for hiring, training, and education as personnel turnover will increase. If a model that includes purchasing and maintaining ambulances is chosen, multiple positions must be in place to manage the extra rolling stock. Each configuration also considers daily supervision.
AP Triton’s algorithm requires supervisor in the field for non-sworn ambulances in service.
This number can fluctuate based on the suppression fire units provide and the area covered by the units.
Contract Compliance Officer
Responsible for reporting requirements and documentation for contractors and LEMSA.
Provide clinical training, CQI review, and training for contractors as needed. Acts as liaison between fire and contractor field personnel. Provides training and education for ePCR compliance. Represents the city on EMS committees as required. Coordinates supplies, narcotics, bio waste, and other services as needed. Monitors trends in the system, such as UHU, APOT, changing protocols, and other issues, to assist in long-term planning.
Billing Oversight— Staff Analyst
Provides billing oversight and support for the city, the contractor, and the billing provider. Ensures ePCR data is transferred to the billing provider as required and coordinates with the Contract Compliance Officer if there are issues. Monitors billing and collections and identifies any trends or issues. Monitors unit hours, provides monthly reports, and reconciles with the billing contractor to ensure they match. Monitors enterprise funds to ensure they operate as required and within budget. Coordinates a compassionate billing program for those unable to pay.
EMS Transportation & Optimization Study National City Fire Department
78 Additional Personnel
AP Triton's comprehensive evaluation thoroughly examines key personnel involved in each operational model. However, taking on ambulance operations within the city is a significant responsibility. Once a model is selected, National City will require further assessments to determine system needs.
Existing fire departments are well-positioned to assume this role, 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.
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.
The following is a list of expected overhead costs. Some of these items are included in the current modeling, while others are not. National City should carefully evaluate all potential expenses before selecting a sustainable model for the future, including housing costs.
Administrative Expenses
The following administrative expenses are examples of things that need to be considered when developing an ambulance transport model. The department currently encompasses some of these items, and others are included in the modeling expenses.
Office Rent and Utilities:
• The cost of maintaining administrative offices, including rent, electricity, water, and other utilities.
• Although most office space for a fire-based ambulance program is already in place at the fire department and City facilities, these costs should be figured into the cost of the whole system on a percentage basis.
Office Supplies:
• Expenses related to stationery, printing, and other office materials.
EMS Transportation & Optimization Study National City Fire Department
79 Salaries for Administrative Staff:
• Compensation for personnel handling billing, scheduling, record-keeping, and other administrative tasks.
Training and Continuing Education:
• Costs associated with ongoing training and certification for EMTs, paramedics, and other staff.
• Training materials, instructors, and facilities contribute to overhead expenses. • Initial training is considered in the models later in this study, but ongoing training must be adjusted as budgets are designed.
Licensing and Certification Fees:
• Fees paid to regulatory bodies for licenses, permits, and certifications required to operate an ambulance service.
• These may include state and local licenses, medical director certifications, and vehicle permits.
Dispatch and Communications Equipment:
• Maintaining communication centers, dispatch software, and emergency call- taking infrastructure required expenses.
• Upgrading or replacing communication equipment adds to overhead costs.
Insurance Premiums:
• Ambulance services require various insurance coverages, including liability insurance, workers’ compensation, and vehicle insurance. • Premiums contribute to overhead expenses.
Vehicle Depreciation and Replacement:
• While vehicle maintenance is an operational cost, the long-term depreciation and eventual replacement of ambulances fall under overhead expenses. • Budgeting for vehicle replacement ensures continuity of service.
Quality Assurance and Compliance:
• Costs related to quality improvement programs, audits, and regulatory compliance.
• Monitoring and maintaining compliance contribute to overhead.
EMS Transportation & Optimization Study National City Fire Department
80 Medical Supplies and Equipment Inventory Management:
• Tracking and managing medical supplies, medications, and equipment inventory.
• Inventory management systems and personnel handling this task add to overhead costs.
Marketing and Community Outreach:
• Expenses related to promoting the ambulance service, community education, and outreach programs.
• Marketing materials, events, and personnel contribute to overhead.
Legal and Professional Fees:
• Legal consultations, contracts, and professional services (e.g., accounting) incur costs.
• Ensuring legal compliance and proper financial management is essential.
Previous Compensation
The current contract with AMR Ambulance requires fees that are paid to National City to support the system. This fee must be considered as the city reviews the modeling projections. The city must understand that this positive line item in their budget will not continue to be paid by AMR if they assume the billing role. This amount will be accounted for in the total cost recovery of the system.
Figure 46: National City Current Reimbursements
Cost Center Monthly Fees Average Annual Fees
AMR Pass-Through Fee $26,500 $318,000
Additional Start-Up Costs
Launching an ambulance program requires substantial startup costs, including purchasing ambulances and equipment, hiring and training staff, onboarding administrative personnel, and implementing a billing system. Establishing a reliable funding strategy before pursuing these options is essential to ensure financial stability.
EMS Transportation & Optimization Study National City Fire Department
81 A new transport model will experience an initial funding period with delayed reimbursements. Since billing takes time to establish and stabilize, a transport conducted on January 1st may not see payment for several months, creating a temporary revenue shortfall. This delay does not indicate lost cost recovery but rather deferred payments. Similarly, if a system ceases patient transport on January 1st, payments will continue for several months.
Some operational models may offer reduced startup expenses if a private provider assumes certain costs. National City should evaluate these financial implications to select the most sustainable approach.
EMS Transportation & Optimization Study National City Fire Department
82 COST RECOVERY & FEE REVIEW
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.
Cost Recovery Strategies
Funding
Funding for an Emergency Transport system is primarily
dependent on patient transportation, as outlined in
this report and the payer 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 (Medi-Cal in California), 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.
EMS Transportation & Optimization Study National City Fire Department
83 Transport Fees
If National City opts to manage its EMS transport and billing system, it should also establish its own fee structure. AP Triton recommends that the provider of record set fees that ensure the financial sustainability of the system. The current valuation is based on the fees charged by AMR in the City.
Understanding the payer mix is crucial in assessing how the fee structure impacts cost recovery. A well-balanced fee schedule should align with reimbursement rates and funding mechanisms to support the long-term viability of the EMS system.
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 the 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 and is not currently done in National City. The city can evaluate the impact of additional fees if it chooses to do so in the future.
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 number of transports at 5,000 per year. At this charge, National City would collect nearly 100% of what is being charged, but even at a 90% collection, it would put the total charges at $2,500,000 and the cost recovery at about $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 a 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 mainly 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 considered too low. Many more factors are involved in the collection rate, including the specific payers involved. If National City chooses to be the provider of record in their system, it is recommended to establish a fee structure that allows them to collect 25%–35% of what is billed.
EMS Transportation & Optimization Study National City Fire Department
84 Federal Reimbursement Programs
Public Provider Ground Emergency Medical Transport (PP-GEMT) Reimbursement for patient transport to the hospital is based on the four payer mixes previously outlined in this study. In California, Medi-Cal provides additional avenues to recover costs beyond the initial billing phase.
There are two primary ways to secure additional federal funds for treating Medi-Cal patients:
Intergovernmental Transfer (IGT)— A funding mechanism allowing government entities to transfer funds to the federal government in exchange for matching Medi-Cal payments.
Certified Public Expenditure (CPE)— A program requiring government healthcare providers with taxing authority to demonstrate a financial loss in providing EMS services to Medi-Cal patients to receive reimbursement.
Expected reimbursement for transporting a Medi-Cal patient is approximately $118.00 (with some additional add-ons), regardless of the billed amount. These programs provide transport authorities with opportunities for additional cost recovery, helping to offset financial shortfalls in Medi-Cal-funded transports.
Certified Public Expenditure
To participate in a CPE program, the City must demonstrate a financial loss in providing EMS services. This is achieved through a written certification detailing the total loss divided by the number of Medi-Cal transports, like filing a detailed tax return.
The State submits this documentation to the Federal Government, which then matches up to 50% of the verified loss and returns the funds to the State. Fees are deducted along the process, and the Provider of Record ultimately receives the remaining additional reimbursement.
However, as of January 2023, this program is no longer available for public agencies in California due to the implementation of the Public Provider Ground Emergency Medical Transport (PP-GEMT) program, which has replaced CPEs as the primary cost recovery mechanism.
EMS Transportation & Optimization Study National City Fire Department
85 Intergovernmental Transfer
The second method a public agency can use to demonstrate financial 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. Multiple fire departments in Southern California currently participate in the program.
Reimbursement Programs
Four major Federal programs offer additional reimbursement for the treatment and transportation of Medi-Cal patients in California under the IGT/CPE programs:
• GEMT (Ground Emergency Medical Transportation)
• IGT (Intergovernmental Transfer)
• QAF (Quality Assurance Fund)
• PP-GEMT—(Public Provider Ground Emergency Medical Transportation)—NEW
GEMT
The GEMT is a CPE program. The program entails filling out lengthy annual expenditure reports documenting everything related to the delivery of Emergency Medical Services in the city.3 Using the reports, a “per transport” charge will be established and multiplied by the total number of Medi-Cal transports. The state can leverage this report to reimburse the public agency 50% of the costs. This program became obsolete with the new PP-GEMT program for public providers.
IGT
An IGT program allows public providers to draw down federal matching funds by putting money up to the state and matching funds back to the City.
3 https://www.dhcs.ca.gov/provgovpart/Pages/GEMT.aspx
EMS Transportation & Optimization Study National City Fire Department
86 QAF
The QAF is the Quality Assurance Fee collected by the Department of Health Care Services (DHCS). All providers pay into the fund, and in return, they receive an enhanced amount on every Medi-Cal transport. The organization pays $34.00 per transport. The State then pools that money into the Federal Government and draws matching funds. All managers take their share in managing the program and redistribute the remaining funds back to each provider based on the number of Medi- Cal transports. The enhancement increases the amount received by $220.80 per transport. This program became obsolete with the new PP-GEMT program for public providers, but is still used by private providers.
PP-GEMT
Until January of 2023, most public agencies participated in the GEMT and QAF programs to enhance the cost recovery from Medi-Cal patients. In 2016, the initial designers of the GEMT program went to the State. They attempted to clarify the terms of the program so that the Fire Department, using EMTs and other First Responders on Medical Aids, could use those personnel in the Certified Cost Reports (CPEs). After years of lobbying (that’s why the program has been on hold), 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 Medi-Cal patients they transported. The enhancement is $1,065.00, compared to the previous $339.00. 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 are set to increase over the next year with a reimbursement of $1,158.10 and a payment of $349.00.
The following figure illustrates the steps and cycle of the PP-GEMT program.
4 https://www.dhcs.ca.gov/provgovpart/Pages/PPGEMTIGT.aspx
EMS Transportation & Optimization Study National City Fire Department
87 Figure 47: PP-GEMT Program Steps and Cycle
Future Availability in GEMT Programs
The founders of AP Triton pioneered the Nation’s first Ground Emergency Medical Transport (GEMT) program, setting the standard for how municipalities could leverage federal reimbursement opportunities to stabilize emergency medical services. Since that time, AP Triton has developed nearly a dozen additional GEMT programs, with several more currently in progress across the country. These programs are structured specifically for public providers and operate as entitlement programs, meaning that if a provider meets the eligibility criteria, funding must be made available. This model ensures sustainability for municipal agencies that cannot otherwise recoup the full cost of ambulance transport under traditional Medicaid and Medicare reimbursement rates.
Provider Tax Programs
It is important to understand the critical distinction between GEMT programs and provider tax programs:
• Provider Tax Programs: These programs apply to both public and private providers and are capped by federal regulation. Providers pay a tax that is then used by the state to draw down federal supplemental reimbursement. In California, the two most notable provider tax programs are:
EMS Transportation & Optimization Study National City Fire Department
88 § The Hospital Managed Care Organization (MCO) tax, which applies to major managed care providers such as Kaiser, Blue Cross Blue Shield, and others. § The Quality Assurance Fee (QAF) program, which is specific to private ambulance providers.
Both mechanisms generate supplemental funding, but they also impose a tax burden on participating providers and have been criticized for disproportionately subsidizing private, for-profit entities.
GEMT Programs
By contrast, GEMT and its public provider extension (PP-GEMT) are not provider tax programs. They are entitlement programs that ensure supplemental reimbursement flows directly to public agencies. Municipal fire departments and EMS agencies are statutorily prohibited from generating a profit. Therefore, supplemental reimbursements protect local taxpayers by covering the shortfall created when low-paying government payors (Medicare and Medicaid) fail to meet the true cost of service delivery.
The “Medicaid Loophole” Debate
Federal policymakers are currently scrutinizing what they have labeled the “Medicaid loophole,” a reference to state practices that use provider tax programs to generate unallocated revenue. For example, in California, the hospital MCO tax carries a 10% state administration fee, generating roughly $40 million. The state submits this amount to the Centers for Medicare and Medicaid Services (CMS) for a Federal Medical Assistance Percentage (FMAP) match, which effectively doubles the amount to $80 million. However, the additional funding is not earmarked for a specific Medicaid program. Critics argue this allows states to subsidize non-Medicaid priorities, such as covering healthcare costs for federally ineligible immigrants.
These concerns do not apply to GEMT or PP-GEMT. Because they are entitlement programs specific to public providers, the funds are tied directly to service delivery and cannot be diverted. This makes GEMT and PP-GEMT examples of sound public policy, focused on protecting taxpayers and ensuring continuity of emergency medical services.
EMS Transportation & Optimization Study National City Fire Department
89 Fiscal Stability and System Safeguards
While the PP-GEMT program generates approximately $340 million annually in California, it represents only a small portion of the broader CMS portfolio. Its alignment with hospital funding mechanisms provides additional resilience, as hospitals secure reimbursement levels far greater than those achievable by ambulance providers. This creates a degree of protection for PP-GEMT participants, as any large-scale restructuring of CMS programs would necessarily impact hospital systems first— providing a buffer to public ambulance providers.
In addition, public providers benefit from structural safeguards embedded in local agreements:
• Contractual Protections: Agreements between agencies and contractors—or between agencies and counties—typically include clauses that allow contracts to be reopened in the event of significant changes. These may include shifts in system economics, payer mix, call volume, or future integration that materially impact cost structures.
• Statutory Obligations: Counties are legally obligated to ensure the provision and financing of emergency ambulance services. This obligation ensures that, even under fiscal pressure, the system remains solvent, and services remain uninterrupted.
• 201 Providers: Agencies designated as “201 providers” under California Health and Safety Code §201 have full authority to adjust their systems in response to changes, providing an added layer of local control and long-term sustainability.
There is no plausible scenario where robust emergency ambulance transport services disappear. The system cannot function without fair and reasonable reimbursement, but entitlement programs such as GEMT and PP-GEMT provide essential stability. While adjustments to Medicaid programs are inevitable over time, the structure of GEMT ensures public providers remain protected, local taxpayers are shielded from additional burdens, and communities continue to receive reliable, high-quality emergency medical transport services.
EMS Transportation & Optimization Study National City Fire Department
90 Summary
These four programs fall under a CPE, IGT, or a combination of both. The PP-GEMT program is the current program in place for public agencies and has significantly increased the system's cost recovery. The following figure estimates the PP-GEMT enhancement that National City could see if it becomes the provider of record for the transportation system.
Figure 48: PP-GEMT Cost/Cost Recovery Estimations 2024
Provider
Projected Medi-
Cal Transports
Normal Federal
Reimbursement
Potential
Enhancement
Estimated IGT
Estimated Fee
Non-Payer Fee
(From non-
paying entities)
Cost Recovery
Public 1,849.00 $118.00 $1,158.00 $349.02 $34.90 $30.00 $1,376,016 Private 1,849.00 $118.00 $339.00 $34.00 10% N/A $417,456
EMS Transportation & Optimization Study National City Fire Department
91 SECTION III:
EMS SYSTEM DELIVERY MODELING
EMS Transportation & Optimization Study National City Fire Department
92 EMS DELIVERY OPTIONS &
STRATEGIES
EMS Transport Service Models
AP Triton has evaluated multiple EMS delivery models and presents five options for National City’s consideration. While the City may not fully implement these models, this assessment provides decision-makers with a clear understanding of the costs associated with each approach. The goal is to help National City 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
• Subcontracting services to a private/public provider
• Hybrid model with in-house, non-sworn fire personnel and subcontracting
These ambulance transport models incorporate National City’s known costs 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. Private provider salaries align with industry standards but could be adjusted based on implementation decisions.
Financial Planning and Enterprise Fund
AP Triton recommends that National City establish an enterprise fund (Margin Account) that rolls over annually an amount equaling 10% of the model's operating costs. This fund would help manage cost recovery fluctuations due to call volume and payer mix changes while also supporting potential service expansions if needed.
EMS Transportation & Optimization Study National City Fire Department
93 Comparing Cost Structures
Each model uses a standardized cost structure where applicable, allowing for direct system comparisons. The city must validate each expense based on purchasing contracts and other policies and procedures for the City, outlined in this study, before moving forward.
Fire-Based vs. Private-Based Staffing Models
• Fire-Based Systems: Typically use 24-hour shifts with additional 12-hour partial shifts to manage peak volume.
• Fire-Based Single Role System: Typically uses 24-hour shifts with the addition of 12- hour partial shifts to manage peak volume. They can also staff 12-hour full-time employees, as they are not firefighters.
• Private-Based Systems: Operate under an A/B shift model (e.g., 0700–1900 and 1900–0700) to optimize UHU, reduce overtime, limit shift fatigue, and minimize station costs. This model requires 33% more personnel and a strong part-time workforce.
• Key Differences: Fire-based models reduce full-time employee counts, minimize shift-change inefficiencies, and align with fire training schedules, whereas private-based models prioritize operational efficiency and cost savings.
System Deployment Recommendations
AP Triton’s analysis indicates that a National City EMS transport system would require a minimum of two 24-hour ambulances and one 10- to 12-hour day units to manage peak activity. This recommendation is based on call data, time of day, call concurrency, and potential city-wide deployment strategies.
As implementation progresses, National City may choose to make necessary adjustments to accommodate real-world factors such as Ambulance Patient Offload Times (APOT), training needs, and surge protection. The city might also choose to start with one system, for instance, a subcontracting model, and then transition to an Ambulance Operator model as the system is built out.
If National City selects a specific model, a strategic deployment plan can be developed. Resource allocation will also vary by model; for example, the firefighter- based model will be built with partial or 12-hour shifts staffed as overtime-only positions due to its 56-hour work schedule.
EMS Transportation & Optimization Study National City Fire Department
94 The Single-Role Model
The use of single-role ambulance operators is not a new concept in the fire service, but it is gaining traction as a preferred model. This class of employees offers several benefits while also presenting certain challenges. The city could choose to use this class of employee in other aspects of public safety, like fire department or police department cadets. This could augment or enhance current staffing levels.
If National City chooses to adopt the single-role model, it should explore all available options to enhance staffing reliability and ensure seamless emergency service delivery.
System Costs
Each EMS model offers unique benefits and challenges. Four of the models necessitate hiring personnel and purchasing equipment, which could introduce delays due to long lead times for vehicle procurement.
Our analysis presents various staffing and deployment models, with ambulance employee costs and EMS system expenses detailed by unit hour and total system cost.
These expenses are itemized in tables to outline the specific requirements of each model. For the subcontracting model, a breakdown of itemized costs alongside a total unit hour cost for the entire system is included.
System costs include personnel for overhead, finance, quality assurance, training, and field supervision. Additional expenses such as risk management, fuel, ambulance maintenance, data connectivity, medical supplies, equipment replacement, and billing are incorporated into the total cost. These costs vary significantly depending on National City’s chosen deployment model, current city purchasing contracts, and the number of ambulances acquired.
Subcontracting has historically been the most efficient and cost-effective approach for ambulance transport. However, as unit hour prices have increased, in-house services have become a more viable alternative. If National City opts to provide ambulance transport directly, unit hour costs may be lower than contracting at a higher rate per unit hour.
EMS Transportation & Optimization Study National City Fire Department
95 Depreciating Costs
The following figures detail AP Triton’s cost estimates, with amortization based on a five- year replacement cycle for vehicles and equipment. While this timeframe covers the primary lifespan of most equipment, items such as radios and gurneys often have longer use spans. Each item in the cost center includes a unit hour cost directly related to the number of ambulance hours required in the system.
The table in the following figure is broken down into four columns, described as follows:
Years of Amortization— Most items are depreciated over five years. This is an estimate and shows the cost distributed over that span. If the City purchases equipment with one-time funds, this depreciation cost can be taken off each year's projected expense, but should still be considered when estimating the total cost of the system.
Equipment Estimated Cost— Each item is assigned an estimated cost to project its total system cost. These costs are not meant to be all-inclusive, as contracts and purchasing power can be fluid.
Estimated Total Cost— The total cost is a basic calculation of the number of ambulances estimated in the system multiplied by the depreciated cost. The modeling projects the need for five ambulances to support the system.
Annual Cost per Ambulance— This is the simple depreciated cost per ambulance per year. For instance, a $200,000 ambulance depreciated over five years is $40,000 per year. Understanding there will be interest on loans and other costs associated with purchasing, the city should evaluate these costs before finalizing any purchasing plans.
The cost in the following figure is in the depreciation section of each of the delivery models. These items have been taken from other programs currently running ambulance programs in California. They represent the major cost items when purchasing and outfitting an ambulance for emergency response, but are not all- inclusive. Each model utilizes the same number of units deployed and a reserve fleet of half that of the units deployed. These cost estimates are taken from Model #1.
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96 Figure 49: Estimated Additional Costs When Providing Transport Directly Cost Center–Per Ambulance Years of
Amortization
Estimated
Cost
Estimated
Total Cost
Annual
Depreciated
Cost
Summary of Operating Expenses Depreciated
Ambulance Replacement 5-Years $230,000 $1,150,000 $230,000 Cardiac Monitor 5-Years $52,000 $260,000 $52,000
Make-Ready Equipment 5-Years $25,000 $125,000 $25,000
Data Tablet (3 yr. Amortization) 3-Years $3,000 $15,000 $5,000 Power Gurney 5-Years $72,000 $360,000 $72,000
Ambulance Setup 5-Years $15,000 $75,000 $15,000
Lucas Devices 5-Year $21,000 $105,000 $21,000
Stair Chair 5-Year $5,000 $25,000 $5,000
Total Depreciated cost of each Ambulance $85,000
Number of Ambulances Required for Deployment 5
Amortized Yearly Costs $425,000
Operating Costs
The costs in the following figures represent each delivery model's operating costs, which include purchasing and managing ambulances. These cost estimates will need to be adjusted if a model is chosen. Some costs are associated with all ambulances (five) while others that deal with personnel are only associated with the staffed ambulances (three). Note that each of the cost items that follows is taken from existing California systems that are staffing city-based ambulance programs. These estimates are taken from Model #1.
Ambulance Insurance— Insurance costs for an ambulance will vary from system to system. Each ambulance must maintain insurance coverage.
Fuel/Maintenance/Mechanics/Licenses— These costs for a city or county are usually estimated on a per-vehicle basis. This can vary depending on the type of vehicle and usually does not change if the vehicle drives 1,000 miles vs. 20,000 miles per year. This could be adjusted based on National City’s costs.
Data Connections— Each ambulance is assigned two data tablets for Mobile Data Connections and Electronic Patient Care reporting. This charge is estimated to cover the data connections of each unit.
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ALS Supplies— Each ambulance is stocked with a set of ALS supplies. This list of supplies can vary from County to County. Once the ambulance is stocked with supplies, the operating costs cover the constant resupply.
Training— Training is typically done on-duty throughout the year. The training costs give an estimate for the year to pay for extra training outside normal work hours.
Uniforms— The cost of uniforms covers basic uniform needs per year, per ambulance.
Certifications— The certification covers the basic costs of EMT and PM certifications.
Figure 50: Summary of Operating Costs
Cost Center–Per Ambulance Estimated
Total Cost
Annual
Cost–Per
Ambulance
Summary of Operating Expenses
Ambulance Insurance $13,000 $2,600
Fuel/Maintenance/Mechanic/License $205,000 $41,000
Data Connection $6,000 $1,200
BLS Supplies $65,000 $13,000
ALS Supplies $55,000 $11,000
Training $36,000 $12,000
Uniforms $8,640 $720
Certifications $2,400 $200
Total Yearly Cost per Ambulance $78,208
Number of Ambulances 5
Total Yearly Cost for System $391,040
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98 Public-Private Partnership
The State of California has implemented the Public Provider Ground Emergency Transport (PP-GEMT) program to enhance the benefits paid for Medi-Cal patients. These enhancements for the additional cost recovery in the system will be discussed in the cost recovery section of this study. There is also a cost for the program, estimated at $330.00+ per Medi-Cal transport. The cost analysis for each deployment model includes the current PP-GEMT agreement’s cost, estimated at over $750,000 in FY2025. This additional cost must be considered when comparing these models to the current or future system designs. The additional cost recovery is taken into consideration in the total revenue for each model.
Facilities
The cost analysis for each deployment model does not include facility expenses. In ambulance operations, remote facilities where day and night crews rest are referred to as “Comfort Stations.”
For fire-based models, the assumption is that ambulances would be housed in existing fire facilities at no additional cost. In subcontracting models, facility costs are presumed to be included in the subcontract rate. However, these costs can be revisited in the future based on the chosen deployment model.
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99 Deployment Models
Model #1: Firefighter Transport Model
Fire Agencies Providing Ambulance Transport with Sworn Personnel Model 1 proposes a sworn firefighter/paramedic and sworn firefighter/EMT staffing model for delivering all emergency ambulance services in National City. Data analysis suggests a recommended UHU of 0.35–0.45 for transport units staffed with sworn personnel. This standard will be applied across all transport models utilizing sworn personnel.
Firefighters typically do not work 12-hour shifts, so this model relies on 24-hour ALS units rather than split shifts. To maintain system consistency, total unit hours remain the same across all models.
• Two 24-hour staffed ALS units are recommended.
• One 12-hour flex BLS unit will ensure adequate coverage during peak demand periods.
• These units will operate 421 hours per week or 60 hours per day to meet response time requirements.
Surge unit staffing can be achieved using overtime personnel or reallocating existing fire apparatus personnel during high-demand periods.
Staffing & Cost Overview
The following figure outlines staffing and employee costs for Model #1, including an additional six Firefighter/Paramedics and six Firefighter/EMTs. Salary and benefit calculations are based on National City Fire Department compensation packages.
Figure 51: Model #1— Firefighter Staffing Costs
Type of Personnel # of
Personnel Individual Total Annual
Cost
Firefighter EMT Salary 6 $98,690 $592,140
Firefighter EMT Benefits 6 $32,537 $195,222
Constant Staffing—Overtime FF/EMTs 6 213 hours $64,969
Firefighter Paramedic Salary 6 $111,816 $670,896
Firefighter Paramedic Benefits 6 $36,763 $220,578
Constant Staffing—Overtime FF/PMs 6 213 hours $73,610
STAFFING COSTS $1,817,414
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Along with the costs in the preceding figure, the system cost-center figures will be added to create total system costs. Each model has 24- and 12-hour shifts added for consistency, and each total unit hour calculation. For example, two 24-hour ambulances equate to 17,520 hours yearly; the additional 12-hour ambulance adds 4,380 hours.
Figure 52: Model #1— Firefighter Model Operational Costs System Costs Total Annual Cost/Revenue
Personnel/Staffing Costs $1,817,414
Subcontracting Costs N/A
Operating Depreciation $425,000
Operating Costs $391,040
Administration Costs $312,578
Other Expenses N/A
12-Hour OT Shifts for Peak Staffing $445,325
Total Operational Costs $3,391,357
Figure 53: Model #1— Additional System Costs
Additional System Costs Total Annual Cost/Revenue
Margin/Roll-Over Account/Fund $339,136
Billing (4% Net Collections) $193,362
PP-GEMT Payment (if Applicable) $765,353
Miscellaneous N/A
Total Additional Costs $1,297,850
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Figure 54: Model #1— Total System Summary
Total Administrative Costs Total Annual Cost/Revenue
Total Revenue (Including PP-GEMT) $4,834,044
Model #1 Total Costs $4,689,208
Total Unit Hour Costs $214.12
Total Cost Recovery (Loss) $144,836
Contractual Revenue $318,000
Total Net Cost Recovery (Loss) ($173,164)
Benefits/Challenges— Model #1
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. Implementing this approach requires National City to carefully evaluate its benefits and challenges. This model also includes over $339,136 in a margin fund for continued system support.
Key Benefits
Increased Staffing: Adding 12 sworn personnel could significantly enhance 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.
Challenges and Considerations
Hiring Constraints: Recruiting a large number 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.
Turnover Issues: Promoting paramedics off ambulances may necessitate continuous training and schooling for replacements.
Equipment Procurement Delays: Acquiring ambulances and fire apparatus faces longer lead times than in previous years, potentially extending start-up timelines.
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Higher Cost Model: This model is one of the most expensive, and it does not include subcontracting, with lower net revenues (cost recovery), potentially impacting reinvestment into the EMS system.
Additional Considerations
AP Triton factored in a 40-hour training course in the start-up costs for each model at the end of this section, but did not include the costs of a 6–8-week firefighter academy, which could significantly increase start-up costs. These challenges must be carefully reviewed before National City makes a final decision on implementing this model.
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Model #2: Ambulance Operator Model
Fire Agencies Providing Ambulance Transport Non-Sworn Personnel Model 2 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.
The prices are for salary and benefits, using the standard firefighter benefits package, as there are no current National City single-role personnel.
To meet 421 weekly unit hours, the system requires:
• 10 EMTs and six 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. The model assumes eight part-time personnel to support the system.
Figure 55: Model #2 - Ambulance Operator Staffing Costs Type of Personnel # of
Personnel Individual Total Annual
Cost
AO EMT Salaries (24-hour)4 6 $61,788 $370,728
AO EMT Salaries (12-hour) 4 $42,560 $170,240
AO EMT Benefits 10 $32,537 $325,370
AO EMT Constant Staffing OT 6 192 hours $36,665
AO PM Salaries 6 $78,048 $468,288
AO PM Benefits 6 $36,763 $220,578
AO PM Constant Staffing OT 6 192 hours $46,314
Staffing Costs $1,638,184
Benefits/Challenges— Model #2
Key Benefits
• Flexible Staffing: Utilizes 24-hour units and 12-hour flex shifts, optimizing efficiency compared to sworn models.
• Increased Fire Personnel on Duty: Expands the number of personnel available citywide without increasing sworn firefighter numbers.
• Full System Control: Allows National City to manage staffing levels and add units as needed, independent of private contractors.
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• Firefighter Recruitment Pipeline: Acts as a training and vetting system for future full-time firefighters, as seen in multiple California fire departments. • Higher Net Cost Recovery: Generates significant net revenue over expenses, allowing reinvestment into the EMS system.
Challenges and Considerations
• High Turnover Rates: Single-role EMS personnel typically experience frequent turnover, necessitating continuous hiring and training efforts. • 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.
Financial Overview
The following figure outlines the major cost components of Model #2, including:
• Personnel Costs (full-time and part-time staffing)
• Depreciation & Equipment Costs
• Operating Expenses (ambulance maintenance, fuel, medical supplies) • Administrative Costs (supervision, training, human resources support) • Additional Costs (peak staffing units, margin accounts, billing services)
Projected Net Cost Recovery
The projected net cost recovery for Model #2, calculated by subtracting total operating costs from projected revenue, is $827,799.
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Figure 56: Model #2— Ambulance Operator Model Operational Costs Model Costs/Revenues Total Annual Cost/Revenue
Personnel/Staffing Costs $1,638,184
Subcontracting Costs N/A
Operating Depreciation $425,000
Operating Costs $394,720
Administration Costs $312,578
Other Expenses N/A
12-Hour OT Shifts for Peak Staffing N/A
Total Operational Costs $2,770,482
Figure 57: Model #2— Additional System Costs
Model Costs/Revenues Total Annual Cost/Revenue
Margin/Roll-Over Account/Fund $277,048
Billing (% of Net Collections) $193,362
PP-GEMT Payment (if Applicable) $765,353
Miscellaneous N/A
Total Additional Costs $1,235,763
Figure 58: Model #2— Total System Summary
Model Costs/Revenues Total Annual Cost/Revenue
Total Revenue (Including PP-GEMT) $4,834,044
Option #2 Total Cost $4,006,244
Total Unit Hour Costs $182.93
Total Cost Recovery (Loss) $827,799
Contractual Revenue $318,000
Total Net Cost Recovery (Loss) $509,799
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Model #3: Hybrid Sworn/Non-Sworn
Hybrid Ambulance Transport Services Sworn/Non-Sworn
Model #3 employs a hybrid approach, integrating sworn firefighters and non-sworn (Single-Role) personnel to provide emergency ambulance transportation. This model includes both EMTs and paramedics in safety (sworn) and non-safety (non-sworn) positions, offering increased flexibility in deployment.
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
• 1 single-role staffed 12-hour BLS surge units
The configuration is set up to combine a mix of sworn and non-sworn personnel. There are many ways to configure the system, including starting with a firefighter model and incorporating single-role personnel as the system is built out. If National City selects this model, AP Triton can refine the deployment strategy to better align with operational requirements and future needs.
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Figure 59: Model #3— Hybrid Sworn/Non-Sworn Staffing Costs Employee Count # of
Personnel Individuals Total Annual
Cost
Firefighter EMT Salaries 3 $98,690 $296,070
Firefighter EMT Benefits 3 $32,537 $97,611
Firefighter EMT Constant Staffing OT 3 213 hours $32,484 Firefighter PM Salaries 3 $111,816 $335,448
Firefighter PM Benefits 3 $36,763 $110,289
Firefighter PM Constant Staffing OT 3 213 hours $36,805 AO EMT Salaries (24-hour) 3 $61,788 $185,364
AO EMT Salaries (12-hour) 4 $42,560 $170,240
AO EMT Benefits 7 $32,537 $227,759
AO EMT Constant Staffing OT 3 192 hours $18,333
AO PM Salaries 3 $78,048 $234,144
AO PM Benefits 3 36,763 $110,289
AO PM Constant Staffing OT 3 192 hours $23,157
Staffing Costs $1,877,993
Financial Overview
The following figure details staffing costs and system needs, incorporating personnel and system costs to provide a comprehensive cost analysis for Model #3.
Figure 60: Model #3— Hybrid Model Operational Costs
Model Costs/Revenues Total Annual Cost/Revenue
Personnel/Staffing Costs $1,877,993
Subcontracting Costs N/A
Operating Depreciation $425,000
Operating Costs $394,720
Administration Costs $312,578
Total Other Expenses N/A
12-Hour OT Shifts for Peak Staffing N/A
Total Operational Costs $3,010,291
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Figure 61: Model #3— Additional System Costs
Model Costs/Revenues Total Annual Cost/Revenue
Margin/Roll-Over Account/Fund $301,029
Billing (% of Net Collections) $193,362
PP-GEMT Payment (if Applicable) $765,353
Miscellaneous N/A
Total Additional Costs $1,259,744
Figure 62: Model #3— Total System Summary
Model Costs/Revenues Total Annual Cost/Revenue
Total Revenue (Including PP-GEMT) $4,834,044
Option #3 Total Costs $4,270,035
Total Unit Hour Costs $194.98
Total Cost Recovery (Loss) $564,009
Contractual Revenue $318,000
Total Net Cost Recovery (Loss) $246,009
Benefits/Challenges— Model #3
Key Features
• Flexible Deployment: Allows for 24-hour units and 12-hour flex units, optimizing resource allocation.
• Balanced Workforce: Six EMTs and paramedics from sworn ranks and 10 EMTs and paramedics from non-sworn ranks to ensure full system coverage. • Strategic Staffing Allocation: All 12-hour surge units will be staffed with non-sworn personnel, maximizing cost efficiency.
• Turnover Management: Retaining non-sworn Ambulance Operators (AOs) may be a long-term staffing challenge.
• Recruitment and Training: Hiring both sworn and non-sworn personnel at scale requires a significant commitment to recruitment, onboarding, and benefits administration.
• Transition Model Feasibility: Along with Model #5, this hybrid approach could serve as a transitional model, ensuring service continuity while National City evaluates long-term EMS solutions.
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Model #4: Private/Public Subcontracting
Private Ambulance Subcontracting for Transport Services Model #4 presents a subcontracting approach, where National City would contract with a private or public provider for all emergency ambulance services while retaining Provider of Record status. This model allows National City to participate in federal reimbursement programs and oversee EMS transport services without directly staffing ambulance units.
Key Features
• Private Provider Partnership: National City contracts a private company to deliver emergency ambulance services.
• Public Provider Partnership: National City contracts a public provider to deliver emergency ambulance services.
• Provider of Record Status: The City maintains oversight, administrative control, and financial management of the system.
• Billing and Revenue Management: National City manages the system’s revenue and expenditures while contracting out billing services.
Proven Success
This approach, commonly referred to as the "Alliance Model" or "Unit Hour Model," has been successfully implemented in Contra Costa City for the past seven years and in other California-based EMS systems.
Cost Considerations
Variable Private Provider Pricing: Unit-hour costs have fluctuated significantly in recent years. In Orange County, CA, BLS service costs are under $100/unit hour, while in San Diego County, the cost could exceed $200/unit hour for BLS service.
Projected Cost per Unit Hour: AP Triton used an estimated $250/unit hour for ALS services and $200/unit hour for BLS services. This is an estimate of possible private provider services and will give the city a better understanding of the relationship between the unit hour cost recovery feasibility.
Alternate Cost per Unit Hour: If the City chooses to contract with a public provider for transport services, the cost per unit hour should be less, considering the difference between cost recovery and profit margin.
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Administrative Costs: To maintain consistency with other models, some administrative expenses were included, slightly increasing the total unit hour cost beyond the base rate from private providers.
Financial Overview
The following figure details the estimated costs of the Subcontracting Model, including:
• Hourly Rate and Unit Hours Required
• Annual Contract Costs
• Additional System Costs
• Revenue Projections After Expenses
Figure 63: Model #4— Subcontracting Model Costs
Cost Center Hourly Rate Hours Needed Annual Cost
Subcontract ALS Costs $250.00 17,520 hours $4,380,000
Subcontract BLS Costs $200.00 4,380 hours $876,000
Figure 64: Model #4— Subcontracting Model Operational Costs Model Costs/Revenues Total Annual Cost/Revenue
Personnel/Staffing Costs N/A
Subcontracting Costs $5,256,000
Operating Depreciation N/A
Operating Costs $75,600
Administration Costs $141,063
Other Expenses N/A
12-Hour OT Shifts for Peak Staffing N/A
Total Operational Costs $5,472,663
Figure 65: Model #4— Additional System Costs
Model Costs/Revenues Total Annual Cost/Revenue
Margin/Roll-Over Account/Fund $547,266
Billing (% of Net Collections) $193,362
PP-GEMT Payment (if Applicable) $765,353
Miscellaneous N/A
Total Additional Costs $1,505,981
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Figure 66: Model #4— Total System Summary
Model Costs/Revenues Total Annual Cost/Revenue
Total Revenue (Including PP-GEMT) $4,834,044
Option #4 Total Costs $6,978,644
Total Unit Hour Costs $318.66
Total Cost Recovery (Loss) ($2,144,600)
Contractual Revenue $318,000
Total Net Cost Recovery (Loss) ($2,462,600)
Benefits/Challenges – Model #4
There are several advantages to National City with the Subcontracting Model:
• There is potential to leverage a partnership with a private/public subcontractor to better meet the needs of the community and each agency involved. • Model #4 can generate significant net cost recovery to reinvest in the EMS system if the unit hour cost is set to sustain the system. • Leaves all hiring and staffing considerations to the subcontracted provider. • Leaves ambulance and equipment purchasing to the subcontractor. • Can be a cost-effective staffing model to provide this service. • Eliminates role confusion between sworn and non-sworn personnel.
With the Subcontracting Model, National City must be aware of the additional workload during start-up for this Model to begin operations. Points to consider are as follows:
• Requires National City to develop and coordinate an RFP for a private ambulance provider to be the subcontractor.
• For a competitive bid, the selected contracted private provider must be chosen, the contract must be signed, and all National City administrative regulations must be followed.
• It may not be easy to find suitable private ambulance subcontractors because the industry only has a few capable private providers.
• The subcontracting unit hour cost can sometimes be unpredictable and subject to vast differences between counties.
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The Subcontracting Model works because the private/public provider is contracted for all emergency response deployment demands at a fixed unit-hour cost. This cost is negotiated, covers all needed expenditures, depreciation, and equipment renewal for the contracted service period, and includes an agreed-upon profit level to the subcontractor. Responsibilities for National City in the Subcontracting Model include the following:
• National City has operational control of the system and will hold the subcontractor accountable directly for failure to meet the contract's requirements at any time.
• National City is the Provider of Record and performs/subcontracts all billing services for transport in this model.
• As the Provider of Record, National City would also access additional federal funding through the PP-GEMT program.
Although the benefits of the Subcontracting model can be significant, the unit hour price can also make the model unsustainable. As shown in the preceding tables, a $250.00/unit hour is not a sustainable cost point for National City. The following figure shows some examples of unit-hour costs that would bring this model in line with the goals and objectives of the city.
Figure 67: Model #4— Total System Summary (Alternate)
Model Unit Hour Cost Desired Unit Hours Total Costs
ALS Subcontracting $140.00 17,520 $2,452,800
BLS Subcontracting $100.00 4,380 $438,000
Total Potential Subcontracting Costs $2,890,800
Additional System Costs* $1,804,124
Total Revenue $4,834,044
Total Subcontracting / System Costs/Contractual Revenue $4,694,924 Total Positive Cost Recovery $139,120
*Operating Costs, Admin Costs, Margin, Billing, PP- GEMT Payments, Contractual Revenue
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Public Provider Subcontractor Option
In addition to the potential unit hour cost in the preceding figure from a private provider, National City could choose to contract with a public provider with ambulance transport capabilities. This model would look very similar to Model #4, with a unit hour cost that allowed for cost recovery in both systems. National City would take on some of the overhead responsibilities in the field and rely on the contractor for personnel and equipment.
To explore this option, the city would need to negotiate a unit-hour cost that made sense for both systems. Understanding the AO model and its pricing for Model #2 will help guide the city in this negotiation. That model outlines the potential costs of any public provider and can be adjusted based on unique circumstances. Using these guidelines, the city can add an additional line for the contractor’s (public provider’s) cost recovery. The following figure is an example.
Figure 68: Public Provider— Subcontracting Review
Model Information
Total Costs
AO Model Costs (Including some administrative costs for the provider) $2,598,967 Public Provider Additional Admin. Fees @ 20% of Costs $519,793 Total Potential Unit Hour Cost Paid to Public Provider $142.41 Additional System Costs* $1,536,611
Total Revenue $4,834,044
Total Subcontracting / System Costs / Contractual Revenue $4,655,371 Total Positive Cost Recovery $178,673
*Operating Costs, Admin Costs, Margin, Billing, PP- GEMT Payments, Contractual Revenue
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Model #5: Hybrid Subcontracting
Hybrid Ambulance Transport Services— Fire-Based and Subcontracting Model #5 integrates the strengths of multiple models by combining city-operated EMS transport with private provider services. This approach allows National City to directly manage part of the transport capacity while subcontracting the remaining transports.
The division between fire-based and private transport could be structured by geographic area, patient acuity, or an even split.
Proposed Deployment Structure
• One city-operated 24-hour ALS AO-staffed unit
• One private provider 24-hour ALS unit
• One city-operated 12-hour ALS AO-staffed unit
If this model is selected, AP Triton can refine the cost structure to meet National City’s specific operational and financial needs.
Figure 69: Model #5— Hybrid Subcontracting Staffing Costs
Cost Center Hourly Rate Hours Needed Annual Cost
Subcontract ALS Costs $250.00 8,760 hours $2,190,000
Subcontract BLS Costs $200.00 N/A N/A
Total Cost $2,190,000
Cost Center # of Personnel Cost/Employee Total Costs
AO EMT Salaries (24-hour) 3 $61,788 $185,364
AO EMT Salaries (12-hour) 4 $42,560 $170,240
AO EMT Benefits 7 $32,537 $227,759
AO EMT Constant Staffing OT 3 192 hours $18,333
AO PM Salaries 3 $78,048 $234,144
AO PM Benefits 3 $36,763 $110,289
AO PM Constant Staffing OT 3 192 hours $23,157
Staffing Costs $3,159,286
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Figure 70: Model #5— Hybrid Subcontracting Model Operational Costs Model Costs/Revenues Total Annual Cost/Revenue
Personnel/Staffing Costs $969,286
Subcontracting Costs $2,190,000
Operating Depreciation $255,000
Operating Costs $264,800
Administration Costs $312,578
Total Other Expenses N/A
12-Hour OT Shifts for Peak Staffing N/A
Total Operational Costs $3,991,664
Figure 71: Model #5— Additional System Costs
Model Costs/Revenues Total Annual Cost/Revenue
Margin/Roll-Over Account/Fund $399,166
Billing (% of Net Collections) $193,362
PP-GEMT Payment (if Applicable) $765,353
Miscellaneous N/A
Total Additional Costs $1,357,881
Figure 72: Model #5— Total System Summary
Model Costs/Revenues Total Annual Cost/Revenue
Total Revenue $4,834,044
Option #2 Total Cost $5,349,545
Total Unit Hour Costs $244.27
Total Cost Recovery (Loss) ($515,501)
Contractual Revenue $318,000
Total Net Cost Recovery (Loss) ($833,501)
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Benefits/Challenges— Model #5
This model could dampen some of the downsides of previous models, while emphasizing the benefits. A stair-step approach could ease the significant lift of launching a new program, reducing the entry burden. Multiple ways exist to split the services between National City and a private provider:
• Lower Start-Up Burden: Reduces initial hiring, equipment procurement, and training challenges compared to fully in-house models.
• Gradual Implementation: A phased approach allows for a smoother transition, minimizing supply chain and operational challenges.
• Flexible Service Allocation: Transport responsibility can be dynamically distributed between National City and the private provider. • Potential for Additional Federal Funding: As the Provider of Record, National City may qualify for PP-GEMT reimbursement, increasing financial viability.
This model balances cost efficiency, operational control, and service scalability, making it a strong transitional option or long-term solution depending on National City’s objectives. This model also has the downsides of model #4, with higher-than- acceptable unit-hour costs. The city must account for sustainable unit hour costs from any private provider it attempts to partner with.
Governance Structure
A critical element of any EMS system in California is the collaboration with the State Emergency Medical Services Authority (EMSA) and the Local Emergency Medical Services Authority (LEMSA). These agencies oversee and regulate pre-hospital emergency medical care, ensuring that EMS operations align with statewide and regional standards. National City falls under the California Health and Safety Code regulation and must adhere to LEMSA policies and procedures governing the safe and efficient transportation of patients within the city.
Regulatory Compliance and Legal Considerations
National City’s EMS system must comply with state mandates and LEMSA’s operational guidelines, which include ambulance deployment strategies, response time standards, data reporting requirements, and medical oversight. Changes to the City's EMS structure, such as adopting a new transport model, may require LEMSA approval and compliance with existing regulations.
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Impact of California Health and Safety Code Sections 1797.201 & 1797.224 AP Triton recommends that National City consult with the City Attorney to evaluate how its designation under California Health and Safety Code Sections 1797.201 or 1797.224 affects ambulance service operations. These statutes impact a city's authority to administer EMS services, with 1797.201 providing municipalities that operated EMS services before June 1, 1980, the ability to retain control, while 1797.224 allows for competitive processes in selecting exclusive operating areas (EOAs). Understanding the City’s legal standing under these statutes will clarify whether National City has full regulatory authority over EMS transport or must coordinate with LEMSA for service modifications.
Strategic Collaboration with LEMSA & EMSA
National City should proactively engage with LEMSA and EMSA to align its EMS strategy with regulatory expectations. This includes:
• Submitting system updates for review and approval
• Ensuring compliance with reporting and performance benchmarks • Advocating for necessary changes or exemptions if needed
By maintaining a collaborative relationship with these agencies, National City can optimize EMS service delivery while ensuring regulatory alignment and legal clarity for any chosen transport model.
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Startup Costs
If National City chooses Models 1, 2, or 3, there will be significant startup costs, including:
• Ambulance and equipment purchases
• Hiring, orientation, and training of personnel
• Overhead expenses
• Billing system setup
Before proceeding with these models, the funding method must be determined. The deployment plans outlined in this report include a cost center designed to recover startup costs within five years to establish financial sustainability.
In contrast, Model #4 (Subcontracting Model) significantly reduces startup costs compared to in-house models. This model primarily requires:
• Overhead costs
• Billing system establishment (AP Triton recommends outsourcing billing to a specialized provider)
Model #5 (Hybrid Model) offers a phased implementation approach, allowing National City to start with minimal startup costs by initially relying on subcontracting. Over time, the city can transition to an ambulance operator model as resources, funding, and personnel become available. This flexible approach helps mitigate financial and operational risks while ensuring long-term system scalability.
Hiring and Orientation
Additionally, if National City chooses Options 1, 2, 3, or 5, the following figures outline an estimated initial hiring cost for both sworn and non-sworn personnel. These non-sworn estimates also consider the establishment of part-time employees to cover openings and maintain a more flexible workforce. For this model, there are 16 full-time employees and eight part-time employees.
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Figure 73: Estimated Hiring Costs for Non-Sworn Employees Cost Center Cost Each Total
Recruiting $20.00 $480
Testing $40.00 $960
Prints/DOJ $49.00 $1,176
Background (Full-time / Part-Time Employees) $240.00 $5,760 Medical (Full-time / Part-Time Employees) $600.00 $14,400 HR Processing $150.00 $3,600
PM Orientation Hours Hourly * 40 hours $5,760
EMT Orientation Hours Hourly * 40 hours $4,560
Orientation/Training Facility $8000.00 $8,000
Safety Gear $350.00 $5,600
Supplies $200.00 $3,200
Total $53,496
Figure 74: Estimated Hiring Costs for Sworn Firefighters
Cost Center Cost Each Total
Recruiting $20.00 $240
Testing $40.00 $480
Prints/DOJ $49.00 $588
Background $1,200.00 $14,400
Medical $600.00 $7,200
HR Processing $150.00 $1,800
PM Orientation Hours Hourly * 40 hours $9,216
EMT Orientation Hours Hourly * 40 hours $8,134
Orientation/Training Facility $8000.00 $8,000
Safety Gear $3,500.00 $42,000
Supplies $200.00 $2,400
Total $94,457
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Summary of Transportation Models
Not all presented models show a positive net cost recovery for the city. The subcontracting model uses a $250/ALS unit hour price point, which is over the top amount the city could pay with the current configuration. The cost recovery is one factor in choosing a model; the benefits and challenges must also be considered.
Figure 75: Ambulance Transport Model Summary
Model Costs/Revenues Model #1
Firefighter
Model #2
AO
Model #3
Hybrid
Model #4
Subcontract
Model #5
AO/Sub
Personnel/Staffing Costs $1,817,414 $1,638,184 $1,877,993 N/A $969,286 Subcontracting Costs NA NA NA $5,256,000 $2,190,000
Operating Depreciation $425,000 $425,000 $425,000 N/A $255,000 Operating Costs $391,040 $394,720 $394,720 $75,600 $264,800 Administration Costs $312,578 $312,578 $312,578 $141,063 $312,578 Total Other Expenses NA NA NA NA NA
12-Hour OT Staffing $445,325 N/A N/A N/A N/A
Total Operational Costs $3,391,357 $2,770,482 $3,010,291 $5,472,663 $3,991,664 Margin/Roll-Over
Account/Fund $339,136 $277,048 $301,029 $547,266 $399,166 Billing (4.00% Net Collections) $193,362 $193,362 $193,362 $193,362 $193,362 PP-GEMT Payments $765,353 $765,353 $765,353 $765,353 $765,353 Miscellaneous Extras @ 5% NA NA NA NA NA
Total Administrative Costs $1,297,850 $1,235,763 $1,259,744 $1,505,981 $1,357,881 Total Revenue $4,834,044 $4,834,044 $4,834,044 $4,834,044 $4,834,044 Total Costs $4,689,208 $4,006,244 $4,270,035 $6,978,644 $5,349,545 Total System Cost per Unit Hour $214.12 $182.93 $194.98 $318.66 $244.27 NET Revenue $144,836 $827,799 $564,009 ($2,144,600) ($515,501) Contractual Revenue $318,000 $318,000 $318,000 $318,000 $318,000 Model Net Revenue (Loss) ($173,164) $509,799 $246,009 ($2,462,600) ($833,501) NOTE: Each model maintains a 10% Margin account that should be considered along with the Model’s Net Revenue (Loss) totals.
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Figure 76: Ambulance Transport Model Summary (Unit Hour/Net Recovery) Ambulance Transport Models Unit Hour Cost Net Cost
Recovery
Model #1—Firefighter Model $214.12 ($173,164)
Model #2—Ambulance Operator Model $182.93 $509,799
Model #3—Hybrid FF/AO Model $194.98 $246,009
Model #4—Subcontracting Model* $318.66 ($2,462,600)
Model #5—Hybrid AO/Subcontracting Model $244.27 ($833,501) *The subcontracting model is set at a $250.00 unit hour price for the private provider; the additional $68 represents additional costs to the City, itemized in the cost analysis.
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APPENDIX A: TABLE OF FIGURES
Figure 1: NCFD Overall Service Area ...................................................................................... 15 Figure 2: Criteria Utilized to Determine Fire Station Condition ............................................. 19 Figure 3: Station 34 ................................................................................................................... 20 Figure 4: Station 31 ................................................................................................................... 21 Figure 5: Station 33 ................................................................................................................... 22 Figure 6: Summary of the NCFD Fire Station Features (2022) .............................................. 23 Figure 7: Criteria Used to Determine Apparatus & Vehicle Condition ............................... 24 Figure 8: NCFD Fleet Inventory (2022) .................................................................................... 25 Figure 9: Economic Theory of Vehicle Replacement .......................................................... 26 Figure 10: Data Skew ................................................................................................................ 30 Figure 11: Overall EMS Incident Density (2020–2024) ........................................................... 32 Figure 12: Ambulance Assigned Incidents (2021–2024) ....................................................... 33 Figure 13: Top 10 Addresses (2021–2024) ............................................................................... 34 Figure 14: Annual Incident Volume (2020–2024) .................................................................. 35 Figure 15: Monthly Incident Demand Variation (2020–2024) .............................................. 35 Figure 16: Variation by Weekday (2020–2024) ...................................................................... 36 Figure 17: EMS Hotspot Counts DAYTIME (2020–2024) .......................................................... 37 Figure 18: EMS Hotspot Counts NIGHTTIME (2020–2024) ....................................................... 38 Figure 19: Incident Volume Percent by Hour (2020–2024) ................................................... 39 Figure 20: Incident Demand by Hour and Day (2020–2024) ............................................... 40 Figure 21: Concurrent Incidents Totality (2020–2024) ........................................................... 41 Figure 22: Concurrent Incidents by Year (2020–2024) .......................................................... 41 Figure 23: NCFD Average Unit Type Commit Time by Incident Category (2020–2024) ... 42 Figure 24: AMR Average Unit Type Commit Time by Incident Category (2020–2024) ..... 42 Figure 25: Predicted Total Number of Units Needed by Hour and Day (2024) ................. 44 Figure 26: 4-Minute Drive Time ................................................................................................ 45 Figure 27: 8-Minute Drive Time ................................................................................................ 46 Figure 28: Response Time Continuum .................................................................................... 48 Figure 29: Alarm Processing Time Performance (2019–2021) .............................................. 48 Figure 30: NCFD System Turnout Time Performance (2020–2024) ....................................... 49 Figure 31: NCFD EMS System Travel Time Performance (2020–2024) .................................. 50
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Figure 32: NCFD EMS Response Time Performance (2020–2024) ........................................ 50 Figure 33: NCFD EMS Total Response Time Performance (2020–2024) ............................... 51 Figure 34: 17-Year Population Forecast with 95% Confidence Bands ................................ 54 Figure 35: 2023 Population Distribution .................................................................................. 55 Figure 36: Service Demand Projection to 2041 ..................................................................... 56 Figure 37: Medicare and Medi-Cal Allowable Charges ...................................................... 63 Figure 38: Calculated Payer Mix ............................................................................................. 68 Figure 39: Authorized National City Rates for Services ......................................................... 69 Figure 40: Transportation Reimbursement Calculation ........................................................ 69 Figure 41: Payer Mix Reimbursement ..................................................................................... 70 Figure 42: Standard Unit Hour Utilization Rates ...................................................................... 72 Figure 43: Determining Adequate TOT 24 hours ................................................................... 73 Figure 44: Number of Incident Responses by Unit (2020–2024) ........................................... 73 Figure 45: UHU/Medical Aid Information ............................................................................... 74 Figure 46: National City Current Reimbursements ................................................................ 80 Figure 47: PP-GEMT Program Steps and Cycle ..................................................................... 87 Figure 48: PP-GEMT Cost/Cost Recovery Estimations 2024 .................................................. 90 Figure 49: Estimated Additional Costs When Providing Transport Directly ........................ 96 Figure 50: Summary of Operating Costs ................................................................................ 97 Figure 51: Model #1—Firefighter Staffing Costs .................................................................... 99 Figure 52: Model #1—Firefighter Model Operational Costs .............................................. 100 Figure 53: Model #1—Additional System Costs .................................................................. 100 Figure 54: Model #1—Total System Summary ..................................................................... 101 Figure 55: Model #2 - Ambulance Operator Staffing Costs .............................................. 103 Figure 56: Model #2—Ambulance Operator Model Operational Costs ......................... 105 Figure 57: Model #2—Additional System Costs .................................................................. 105 Figure 58: Model #2—Total System Summary ..................................................................... 105 Figure 59: Model #3—Hybrid Sworn/Non-Sworn Staffing Costs ........................................ 107 Figure 60: Model #3—Hybrid Model Operational Costs .................................................... 107 Figure 61: Model #3—Additional System Costs .................................................................. 108 Figure 62: Model #3—Total System Summary ..................................................................... 108 Figure 63: Model #4—Subcontracting Model Costs .......................................................... 110 Figure 64: Model #4—Subcontracting Model Operational Costs .................................... 110 Figure 65: Model #4—Additional System Costs .................................................................. 110
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Figure 66: Model #4—Total System Summary ..................................................................... 111 Figure 67: Model #4—Total System Summary (Alternate) ................................................. 112 Figure 68: Public Provider—Subcontracting Review .......................................................... 113 Figure 69: Model #5—Hybrid Subcontracting Staffing Costs ............................................ 114 Figure 70: Model #5—Hybrid Subcontracting Model Operational Costs ........................ 115 Figure 71: Model #5—Additional System Costs .................................................................. 115 Figure 72: Model #5—Total System Summary ..................................................................... 115 Figure 73: Estimated Hiring Costs for Non-Sworn Employees ............................................. 119 Figure 74: Estimated Hiring Costs for Sworn Firefighters ...................................................... 119 Figure 75: Ambulance Transport Model Summary ............................................................. 120 Figure 76: Ambulance Transport Model Summary (Unit Hour/Net Recovery) ................ 121
RESOLUTION NO. 2025 -
RESOLUTION OF THE CITY COUNCIL OF THE CITY OF NATIONAL CITY, CALIFORNIA,
ACCEPTING THE EMERGENCY MEDICAL SERVICES (EMS) TRANSPORTATION &
OPTIMIZATION STUDY CONDUCTED BY AP TRITON CONSULTING AND DIRECTING THE
CITY MANAGER TO PURSUE THE DEVELOPMENT OF A MUNICIPAL AMBULANCE TRANSPORT SYSTEM.
WHEREAS, the National City Fire Department (NCFD), in coordination with AP Triton Consulting, conducted a comprehensive Emergency Medical Services (EMS) Transportation & Optimization Study to eva luate operational performance, financial sustainability, and long -term service delivery models; and
WHEREAS, the study found that the NCFD currently provides a high -performing Advanced Life Support (ALS) first -response system covering approximately nine sq uare miles and responding to over 10,000 incidents annually, nearly half of which are medical in nature; and WHEREAS, through its operational and financial assessment, AP Triton identified a significant opportunity to improve fiscal sustainability, system reliability, and local control by transitioning to a City-operated municipal ambulance transport model; and WHEREAS, among the five delivery models evaluated, the Ambulance Operator Model— staffed by non-sworn EMTs and paramedics—produced the strongest financial outcome, with an estimated annual surplus of $509,799 while maintaining service reliability; and WHEREAS, the analysis revealed that a City-operated model would enable participation in federal and state reimbursement programs, including the Public Provider Ground Emergency Medical Transport (PP -GEMT) program and the Quality Assurance Fee (QAF) program, which together could yield an estimated annual fiscal benefit exceeding $900,000; and WHEREAS, when combined with PP -GEMT reimbursement, the system achieves the highest long-term return on investment, providing both fiscal stability and operational control; and WHEREAS, the study further recommends adopting a public provider framework, leveraging supplemental funding programs, implementing an enterprise fund model, investing in a permanent Fire Station 33, and maintaining data -driven oversight using continuous QA /QI performance metrics; and
WHEREAS, the findings demonstrate that a City -operated ambulance transport system would enhance service reliability, improve fiscal sustainability, and align with National City’s goal of providing equitable, high-quality emergency medical care to all residents.
NOW, THEREFORE, THE CITY COUNCIL OF THE CITY OF NATIONAL CITY, CALIFORNIA, DOES RESOLVE, DECLARE, DETERMINE, AND ORDER AS FOLLOWS:
Section 1. That the City Council hereby a ccepts and files the Emergency Medical Services (EMS) Transportation & Optimization Study conducted by AP Triton Consulting.
Section 2. That the City Council also hereby authorizes the City Manager to evaluate the costs associated with the study’s recommendations as part of the subsequent development phase and recommendations will be brought back to the City Council for approval.
Section 3. The City Clerk shall certify to the passage and adoption of this Resolution and enter it into the book of original Resolutions.
PASSED and ADOPTED this 18th day of November, 2025.
Ron Morrison, Mayor
ATTEST:
Shelley Chapel, MMC, City Clerk
APPROVED AS TO FORM:
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Barry J. Schultz, City Attorney