ACTION:
____________________________
Clerk/Secretary
Department: Fire Item No: PH3
Prepared by: Maia Hodge, Management Analyst Meeting Date: December 10, 2024 Approved by:
Gerard Washington, Fire Chief
John Conley, City Manager Agenda Location: Public Hearing SUBJECT: EMERGENCY MEDICAL SERVICES FEES
RECOMMENDATION:
1.Open, conduct and close a public hearing to receive testimony regarding the adoption of emergency medical services fees.
2.Adopt City Council Resolution No. 2024- , amending the Emergency Medical Services Fees schedule.
CORRELATION TO CITY COUNCIL GOALS: Public Safety and Fiscal Responsibility.
PRIOR ACTION: On June 11, 2024, adopted City Council Resolution No. 2024-103, amending the Operating Budget for Fiscal Years 2023/24 and 2024/25 (Vote: 5-0).
On June 13, 2017, adopted City Council Resolution No. 2017-87, amending ambulance transport service fees and establishing a first responder fee (Vote: 5-0).
A comprehensive list of prior actions is included as Exhibit 4.
STATEMENT ON THE SUBJECT:
Emergency Medical Services Fees. All residents and non-residents who utilize the Vista Fire Department Emergency Medical Services are charged fees. Base rates are established to cover the fixed cost of personnel, non-disposable supplies, and equipment assigned to the ambulances. First Responder fees and Ambulance Transport Service fees have not been increased since 2017 while staffing and equipment costs have increased without an adjustment to emergency medical services fees.
The Advanced Life Support 2 (ALS-2) fee covers the highest level of service that can be provided to a patient and is the top tier of the Ambulance Transport Services Fees. The City of Vista’s current ALS-2 base fee is $1,697 for residents, $1,829 for non-residents, and $27 per mile. Staff compared the City’s base charge fees for ambulance transport, first responder (treatment and release fees), and add-on charges with that of neighboring agencies and discovered the City’s current emergency medical services fees are lower in comparison to most agencies among all tiers.
Ambulance Fee Study. In August, 2023, the Vista Fire Department contracted with NBS Government Finance Group (NBS) to conduct an independent review of City of Vista emergency medical services fees for Cost-of-Service Analysis, Fee Establishment, and Cost Recovery Evaluation (Exhibit 3). The results indicated the City’s current first responder fees and ambulance transport fees are lower than most of the AGENDA
REPORT
CITY COUNCIL
COMMUNITY DEVELOPMENT COMMISSION
SUCCESSOR AGENCY
BUENA SANITATION DISTRICT
JOINT POWERS FINANCING AUTHORITY
Opened, conducted, and closed the public hearing. Adopted City Council Resolution No. 2024-202.
Vote: 5-0
MEETING DATE: December 10, 2024 PAGE 2
SUBJECT: EMERGENCY MEDICAL SERVICES FEES
comparison agencies while most direct costs including medications, mileage, supplies, and oxygen fall in the middle of the other comparison agencies surveyed.
In addition, the cost of City of Vista Emergency Medical Services (EMS) continues to rise. Currently, the cost to run the EMS program is approximately $28.1 million, which is 79 percent of total fire department costs, including cost for labor, ambulance replacement, city-allocated overhead costs, and department administrative support. In Fiscal Year 2023, the EMS Division managed 87 percent of all calls for emergency service within the City. The ambulance fee study determined that the average total cost per type of ambulance service is $3,629 for transport, $981 for first responder, and $432 for all other calls.
NBS recommended one fee for all tiers of transport, whether ALS-2, ALS, or BLS (Basic Life Support).
Total cost of service per activity recovery (transport and first responder) was recommended for the cost recovery including publishing all standard add-on charges that the City intends to bill for on a routine basis in the master fee schedule including services provided during transport that vary per incident, such as mileage, oxygen, medications, supplies, and EKG. Lastly, in addition to establishing updated fees for first responder, transport, and add-on charges, the City should consider applying a Consumer Price Index (CPI) inflator annually to keep up with rising costs.
Staff recommend approval of the revised Emergency Medical Services Fee Schedule to be effective January 1, 2025 (Exhibit 2). In addition, the Centers of Medicare & Medicaid Services (CMS) publishes an annual Ambulance Inflation Factor (AIF) adjustment to be effective on July 1 of each fiscal year.
FISCAL IMPACT: Based on the estimates prepared for the Ambulance Fee Study, adoption of the staff recommendation could result in approximately $4,000,000 in additional revenue on an annual basis.
However, predicting the actual effect on City revenues is difficult due to the variability in reimbursement rates among different fee payers. Actual revenues collected will be determined by the number of calls, insurance status, and provider.
EXHIBITS:
1.City Council Resolution No. 2024- , amending the Emergency Medical Services Fees schedule
2.Emergency Medical Services Fees Schedule
3.NBS City of Vista Fire Department Ambulance Rates Study
4.Prior Actions
12/10/2024 PH3 2 of 29
00029213 7
RESOLUTION NO. 2024-
A RESOLUTION OF THE CITY COUNCIL OF THE CHARTERED CITY OF
VISTA, CALIFORNIA, AMENDING THE EMERGENCY MEDICAL SERVICES
FEE SCHEDULE
The City Council of the City of Vista does resolve as follows:
1. Findings. The City Council hereby finds and declares the following:
A. Pursuant to Emergency Medical Services System and the Pre-hospital Emergency Medical Care Personnel Act commencing at Section 1797 of the California Health and Safety Code, the City of Vista, acting through its Fire Department, is authorized to provide ambulance transportation and emergency medical services within the territory of the City of Vista and the Vista Fire Protection District; and
B. Pursuant to Article XI, sections 7 and 9, respectively, of the California Constitution, the City of Vista is authorized to make and enforce regulations not in conflict with the general laws of the State, and to provide transportation services, including ambulance and emergency medical transportation; and
C. The City Manager has presented a report and recommendations to the City Council regarding the operation of the City’s ambulance transport services and the provision of emergency medical services, including recommendations that the existing fees and charges for such services do not cover the current cost of providing such services; and D. 43 U.S.C. § 1834(I) (3) (B) of the Social Security Act establishes an inflation factor equal to the percentage increase in the consumer price index for all urban customers (CPI-U) for the 12-month period ending with June of the previous year for updating payment limits that Medicare carriers use to determine how much to reimburse providers and suppliers of ambulance services. This percentage increase is referred to as the Ambulance Inflation Factor (AIF); and
E. The Consumer Price Index (CPI) Series Title Medical Care in the U.S. City Average, All Urban Consumers, Not Seasonally Adjusted, as published by the U.S. Department of Labor, Bureau of Labor Statistics establishes a CPI index inflator as a percentage change for the twelve (12) month period ending December 31 of the preceding calendar year; and F. The City Council desires to automatically adjust first responder fees, ambulance transport fees, and add-on charges each year according to the AIF and CPI-U.
2. Action.
A. Effective January 1, 2025, the Vista Fire Department Emergency Medical Services Fee Schedule, as described in Exhibit 2, attached hereto and incorporated herein by reference are approved.
B. Effective July 1, 2025, and thereafter, Emergency Medical Services fees shall be increased on July 1 of each year in conformity with the AIF and CPI-U. 12/10/2024 PH3 3 of 29
EXHIBIT 1
RESOLUTION NO. 2024-
CITY COUNCIL OF THE CHARTERED CITY OF VISTA
PAGE 2
00029213 7EXH 01 Emergency Medical Services Fees 2024 Resolution template -C.docx
3. Adoption. PASSED AND ADOPTED at a meeting of the City Council of the City of Vista held on December 10, 2024, by the following vote:
AYES:
NOES:
ABSTAIN:
APPROVED AS TO FORM:
WALTER CHUNG, CITY ATTORNEY
By:
APPROVED
Walter C. Chung
20241126084830
JOHN B. FRANKLIN, MAYOR
ATTEST:
KATHY VALDEZ, CITY CLERK
By:
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EXHIBIT 2
00050181 2 1
Vista Fire Department
EMERGENCY MEDICAL SERVICES FEE SCHEDULE
Revised December 10, 2024
1.First Responder Fee $981
This fee will be applied to all Vista resident and Vista non-resident treatment and release bills where a Vista ALS fire engine arrives on scene and a patient assessment is performed resulting in the generation of a patient care report.
2.Transport Fees
Resident Advanced Life Support 2 (ALS2)$3,629
Non-Resident Advanced Life Support 2 (ALS2)$3,629
Resident Advanced Life Support (ALS)$3,629
Non-Resident Advanced Life Support (ALS)$3,629
Resident Basic Life Support (BLS)$3,629
Non-Resident Basic Life Support (BLS)$3,629
Mileage (per loaded mile or fraction)$27
3.AMA/Treat and Release
This will include the first responder fee plus any of the following additional charges that apply.
4. Procedures/Supplies
Oxygen $65
EKG (for Medi-Cal patients only if they receive $20
service) Intubation (ET/LMA/King)$60
Defibrillation/Cardioversion $60
5.Disposable Charges
Disposable Supplies Level I $65
•If any of the following supplies are used on a patient, they will incur a single charge for Disposable Supplies I, unless one of the items listed under Disposable Supplies II is used, then they will receive the Disposable Supplies II fee. •Items included in Disposable Supplies Level I include ECG, glucose monitor, medication administration (IV, IM, IN, Nebulized) NG/ OG, restraints, cervical/spinal stabilization, bleeding control/splinting/bandaging, splinting, suction.
Disposable Supplies Level II $150
•If any of the following supplies are used on a patient, they will incur a single charge for Disposable Supplies II, and the Disposable Supplies I fee will not be added. •Items included in Disposable Supplies Level II include CPAP, airway management/adjunct, Magill forceps, cardiac pacing, childbirth, interosseous, CPR, needle decompression, chest seal.
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EXHIBIT 2
EXHIBIT 2
00050181 2 2
6. Pharmaceuticals
Pharmaceuticals Cost+ 55%
Rounded to the nearest dollar
7.AIF and CPI-U Annual Adjustment
First responder fees, ambulance transport fees, and add-on charges adjusted annually, beginning July 1, 2025, and each July 1st thereafter, in conformity with the Ambulance Inflation Factor (AIF) by the percentage change in the Consumer Price Index Series Title Medical Care in the U.S. City Average, All Urban Consumers (CPI-U), Not Seasonally Adjusted, as published by the U.S. Department of Labor, Bureau of Labor Statistics for the twelve (12) month period ending December 31 of the preceding calendar year. 12/10/2024 PH3 6 of 29
nbsgov.com
Corporate Headquarters
32605 Temecula Parkway, Suite 100
Temecula, CA 92592
Toll free: 800.676.7516
Prepared by:
FINAL REPORT
Report for:
Ambulance Rates Study
September 18, 2024
Corporate Headquarters
32605 Temecula Parkway, Suite 100
Temecula, CA 92592
Toll free: 800.676.7516
Prepared by:
nbsgov.com12/10/2024 PH3 7 of 29
EXHIBIT 3
TABLE OF CONTENTS
Executive Summary ........................................................................................................ 1 Project Approach ............................................................................................................ 3
2.1 Legal Foundation ..................................................................................................... 3
2.2 Project Approach ..................................................................................................... 4 Analysis .......................................................................................................................... 9
3.1 Cost-of-Service Analysis .......................................................................................... 9
3.2 Fee Establishment ................................................................................................. 14
3.3 Cost Recovery Evaluation ...................................................................................... 15 Conclusion .................................................................................................................... 20 12/10/2024 PH3 8 of 29
CITY OF VISTA
Ambulance Rates Study 1
EXECUTIVE SUMMARY
NBS performed a study of the City’s fees for ambulance services. Services studied include ambulance transport and/or treatment without transport. The City’s primary purpose in conducting this Study was to ensure that fees do not exceed the costs of providing services and provide an opportunity for the City Council to set fee amounts according to local cost recovery policy.
The body of this report illustrates calculation of the maximum fee amounts that reflect the City’s full costs of providing services, as well as the policy options for considering implementation of fee amounts at or below that ceiling.
This Study identified approxim ately $28.1 million in total annual City costs of providing Emergency Medical Services (EMS ). The Cit y collects $3.2 million, per year, on average, for ambulance services at current fee amounts . At face value, it appears the City has potential to recover more than $20.9 million per year in costs for these services. However, review of historical EMS calls for service data showed that not all calls result in an ambulance transport and/or treatment without transport service. Of those calls that do result in ambulance transport and/or treatment without transport service, there are instances when no bill for service occurs. Additionally, most bills for ambulance services do not result in full payment.
Depending on whether the recipient of a bill is a private or public insurance company, or individual, significant write downs, write offs, and payment delays occur. Based on an analysis of billing and revenue receipts data, the City’s receives, on average, approximately 33% of the annually billed amount for services.
As shown in Table 1 on the next page, at current annual billing activity levels, the City could increase “Average Annual Billings at Current Fees” from $10.8 million to the “100% Full Cost Recovery Fee Levels” of $29.9 million per year. The “Collected” row of the table considers that the average revenue received is 33% of annual billings due to write offs, which would result in a collected amount increase from $3.2 million to $9.8 million. Therefore, the net potential increase in revenue received by increasing current fees to full cost recovery fee amounts is an estimated $6.6 million.
As discussed in Section 2.2.3 of this report, there may be local policy considerations for adopting fees at less than the calculated full cost recovery amount. Also, the Centers for Medicare and Medicaid Services (CMS) sets limits, or “caps,” for how much a provider can be reimbursed for administering ambulance services. CMS, however, does not regulate how much can be charged to individual patients or private insurance companies. All these considerations and nuances will impact the amount of revenue ultimately collected from any increase in ambulance fees for services.
Section 3.3.1 of this report presents three cost recovery options for consideration:
• Option 1: Transport fees established at 100% full cost recovery; Add -on charges assumed at no change from current fee amounts
• Option 2: Transport fees and Add-on charges established at the average of the regional comparison
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CITY OF VISTA
Ambulance Rates Study 2
• Option 3: Transport fees at the average of the five agencies selected in the comparison survey; Add-on charges assumed at current cost
Table 1 shows a summary of annual estimated revenue projections for each of the policy options described.
TABLE 1. REPORT SUMMARY
As shown, the potential net increase in revenue from increasing current fees to one of the presented policy options in this report is estimated at between $3.2 million and $6.6 million. However, predicting the amount to which adopted fee increases will truly affect City revenues is difficult, given that reimbursement rates for different types of fee payers ultimately drives what percentage of any bill for ambulance services is actually paid.
Average Annual
Billings at Current
Fees
Option 1
-
100% Full Cost
Recovery Fee
Levels
Option 2
-
Regional Fee -
Average
Option 3
-
Average of the
Five Comparison
Agencies Selected
Billed $ 10,810,992 $ 29,884,973 $ 19,488,120 $ 20,931,927 Collected $ 3,240,784 $ 9,838,133 $ 6,415,489 $ 6,890,790 Net Collected Revenue
Increase $ 6,597,349 $ 3,174,705 $ 3,650,006 12/10/2024 PH3 10 of 29
CITY OF VISTA
Ambulance Rates Study 3
PROJECT APPROACH
In approaching any fee study, NBS assesses the unique conditions of the agency with which we work, applies a core philosophy, and selects methodologies that best fit the requirements of the individual agency. Given the diversity and nuances present in many aspects of city finance and policy, this is a necessary strategy since one-size-fits-all methods are not sustainable once they become owned by the agency served.
There is a legal foundation in place that provides the City with the authority to impose fees for the services it provides. The cost of providing these services and activities can be reasonably calculated and fees can be structured in a manner that allows the City to recover up to 100% of service costs. The calculation of the cost of providing services is an analytical effort that involves adopted and expected cost information and estimates of time (or time tracking information) required to perform a service or activity.
Determining the targeted level of cost recovery from a new or increased fee is not an analytical exercise.
It involves agency-specific judgments linked to a variety of factors, such as existing City policies, agency - wide or departmental revenue objectives, economic goals, community values, market conditions, level of demand, and others. Further, the Centers for Medicare and Medicaid Services (CMS) sets limits, or “caps,” for how much a provider can be reimbursed for administering ambulance services. CMS, however, does not regulate how much can be charged to patients or private insurance companies. If the adopted fee is set at an amount that does not exceed the estimated and reasonable full cost of providing the service or activity requested, the City is in compliance with the legal framework currently in place.
2.1 Legal Foundation
In California, there is great variability amongst fees charged to individuals for receiving ambulance transport and/or treatment. There is no set standard in California locally or statewide for how ambulance fees and rates should be calculated or administered. Therefore, in our opinion, the foundation for justification of ambulance fees for services needs to rely on a combination of federal guidelines and requirements as well as California state authorities for charging fees.
CMS is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid. CMS develops a national Ambulance Fee Schedule for services eligible for partial reimbursement to providers. CMS sets limits, or “caps,” for how much a provider can be reimbursed for administering ambulance services. CMS, however, does not regulate how much can be charged to patients or private insurance companies. For the ambulance transport benefit under Medicare Part B, an annual update is applied to the payment limits for ambulance transports that is equal to the percentage increase in the Consumer Price Index for All Urban Consumers (CPI -U) for the 12-month period ending with June of the previous year. This study relies on several of the CMS guidelines to structure which types of fees are charged for Medicare and Medicaid billing purposes.
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CITY OF VISTA
Ambulance Rates Study 4
It is generally accepted in California that cities are granted the authority to impose user and regulatory fees for services and activities they provide through provisions of the State Constitution. More specifically, the type of fees the City of Vista seeks to establish for ambulance services fall under the California Constitution Article XIII C. Section 1(e), which provides seven stated exceptions to the State’s definition of a “tax.” The City’s ambulance fees represent cost recovery opportunities entirely within the City’s control. These are revenues which the City Council may, at its sole discretion upon public hearing, implement and/or modify without further public process or approval. The only legal limitation on the establishment of these fees is that they may not exceed the estimated and reasonable costs incurred to provide the service or perform the function for which the fee is charged .
2.2 Project Approach
The fee study is a quantitative effort which compiles the full cost of providing governmental services and activities and translates those costs into proposed fee amounts best aligned with how services are provided. There were three phases of analysis completed during this study:
1. Cost-of-Service Analysis
2. Fee Establishment
3. Cost Recovery Evaluation
2.2.1 COST-OF-SERVICE ANALYSIS
A Cost-of-Service Analysis is a quantitative effort that compiles the full cost of providing governm ental services and activities. There are two primary types of costs considered: direct and indirect costs. Direct costs are those that specifically relate to an activity or service, including the real -time provision of the service. Indirect costs are those that support the provision of services in general but cannot be directly or easily assigned to a singular activity or service. The following are different types of direct and indirect costs that are considered in the Cost-of-Service Analysis:
Direct Costs:
• Direct personnel costs – Salary, wages and benefits expenses for personnel specifically involved in the provision of services and activities to the public. • Direct non-personnel costs – Discrete expenses incurred by the City due to a specific service or activity performed, such as contractor costs, third-party charges, and very specific materials used in the service or activity.
Indirect Costs:
• Indirect personnel costs – Personnel expenses supporting the provision of services and activities. This can include line supervision and departmental management, administrative support within a department, and staff involved in technical support activities related to the direct services provided to the public.
• Indirect non-personnel costs – Expenses other than labor involved in the provision of services.
In most cases, these costs are allocated across all services provided by a department, rather than directly assigned to individual fee categories.
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Ambulance Rates Study 5
• Overhead costs – These are expenses, both labor and non-labor, related to City-wide support services. Support services include general administrative services such as City Manager, Finance, Human Resources, etc.
All cost components in this Study use annual (or annualized) figures, representing a twelve -month cycle of expenses incurred by the City in the provision of services. Once the total estimated annual costs of providing services are known, further analysis is completed to identify service costs that may not be eligible for recovery in the fees subject to study.
To translate the annual costs of providing fee-related services into full cost-recovery individual fee amounts, we applied estimated or tracked time data and estimated or tracked activity data as an indicator of the level of service provided by type of service provided.
2.2.2 FEE ESTABLISHMENT
The Study’s process provided the opportunity to propose additions and deletions to the fee schedule, as well as to rename, reorganize, and clarify fees imposed. Many such revisions better conform fees to current practices, as well as improve the calculation of fees owed by an individual, the application of said fees, and the collection of revenues.
In most cases, the current structure of fees did not change; the focus is to recalibrate the fee amount t o match the costs of services. In several cases, however, fee categories and fee names were simplified or re - structured to increase the likelihood of full cost recovery, or to enhance the fairness of how the fee applies to various types of fee payers.
2.2.3 COST RECOVERY EVALUATION
The fee model compares the existing fee for each service or activity to the average total cost of service quantified through this analysis. A cost recovery rate of 0% identifies no current recovery of costs from fee revenues (or insufficient information available for evaluation). A rate of 100% means that the fee currently recovers the full cost of service. A rate between 0% and 100% indicates partial recovery of the full cost of service through fees. A rate greater than 100% means that the fee exceeded the full cost of service.
Fees examined in this Study should not exceed the full cost of service. In other words, the cost recovery rate achieved by a fee should not be greater than 100%. We assist with modeling the “recommended” or “targeted” level of cost recovery for each fee, always established at 100%, or less, than the calculated ful l cost of service.
As covered in section 2.1 Legal Foundation, while CMS sets limits, or “caps,” for how much a provider can be reimbursed for administering ambulance services, the agency does not regulate how much can be charged to patients or private insurance companies. As such, targets and recommendations always reflect agency-specific judgments linked to a variety of factors, such as existing City policies, revenue objectives, economic goals, community values, market conditions, level of demand, and others. Because this element of the Study is subjective, the results of this study provide the cost-of-service calculation based on 100% 12/10/2024 PH3 13 of 29
CITY OF VISTA
Ambulance Rates Study 6
full cost recovery as well as the framework for the City to adjust in accordance with the City’s goals as pertains to code compliance, cost recovery, economic development, and social values.
2.2.4 COMPARATIVE FEE SURVEY
Often policy makers request a comparison of their jurisdiction’s fees to surrounding or similar communities. As illustrated in the comparison survey, the City’s current Ambulance Transport and Treat and Release fees are lower than most of the comparison agencies. The remaining fees such as EKG, Medications, Mileage, Night Charge, Supplies, and Oxygen fall in the middle of the other comparison agencies surveyed.
While a comparison can provide a sense of the local market pricing for services and be useful in gauging the impact of recommendations for fee adjustments, the following should be noted about the general use of comparative survey data:
• Comparative surveys typically do not provide information about the cost recovery policies or procedures inherent in each comparison agency.
• A “market based” decision to price services below the full cost of service calculation, is the same as deciding to subsidize that service.
• Comparative agencies may or may not base their fee amounts on the estimated and reasonable cost of providing services.
• Comparative fee survey efforts are often non-conclusive for many fee categories. Comparison agencies typically use varied terminology for the provision of similar services.
The results of the Comparative Fee Survey for the City’s Ambulance fees are shown on the following page.
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Ambulance Rates Study 7
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Ambulance Rates Study 8
2.2.5 DATA SOURCES
The following data sources were provided by the City and used to support the cost-of-service analysis and fee establishment phases of this Study:
• Adopted budget for Fiscal Year (FY) 2023-24
• A complete list of the Fire Department’s personnel, salary/wage rates, paid benefits, etc. • Prevailing fee schedules
• Annual ambulance activity and billing data
• Assigned incidents data
• Calls for service data
The City’s adopted budget is the most significant source of information affecting cost of service results.
We did not audit or validate the City’s financial management and budget practices, nor was cost information adjusted to reflect different levels of service or any specific, targeted performance benchmarks. This Study has accepted the City’s budget as a legislatively adopted directive describing the most appropriate and reasonable level of City spending.
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Ambulance Rates Study 9
ANALYSIS
The focus of this Study is on fees charged for ambulance services provided by the City. The following is a summarized list of fees studied:
• ALS – Advanced Life Support includes emergency medical care performed for sustaining life, including cardiopulmonary resuscitation (CPR), defibrillation, airway management, and the administration of drugs and medications. Additional medical procedures may includ e cardiac monitoring, I.V.’s, and the use of diagnostic devices.
• BLS – Basic Life Support generally does not include the administration of drugs or invasive skills.
• Treatment and Release – Flat fee for services applied when the City responds to an emergency call for service, administers care at the scene, and does not transport the patient to hospital.
• Related Add-Ons – Itemized charges allowed by CMS for EKG services, Oxygen, Fuel, Medications, and Night services.
The fees examined in this Study excluded other fire related fees for services, development impact fees, utility rates, and any special tax assessments, all of which fall under distinct legal, analytical, and procedural requirements different from the body of user fees analyzed in this effort. Additionally, this Study excluded fines and penalties imposed by the City for violations to its requirements or codes.
3.1 Cost-of-Service Analysis
A full range of fire and paramedic services are provided by the City’s Fire Department. The Fire Department can be summarized into seven main functional areas for purposes of this analysis:
• Fire Administration - Leadership for the personnel and programs of the department. Also responsible for budgeting, planning, directing, and team building. Sets and reviews department policy and provides administrative support to all Fire divisions. • Fire Training – Coordinates all aspects of employee training, keeping current with the local, state, and federally mandated training requirements.
• Fire Maintenance – Maintenance of all apparatuses and equipment. • Fire Suppression – Emergency response related to fire incidents and other types of emergencies. A significant portion of fire suppression directly supports Emergency Medical Services response.
• Fire Inspection – Annual inspections of commercial buildings, development review, Fire Code permits, investigative and code enforcement activities, etc. • Emergency Medical Services (EMS) – Ambulance response services that typically result in a transport to a hospital or treatment on-scene without a transport. • Disaster Preparation – Involves all city staff in the planning, preparation, and mitigation of any major emergency or regional disaster.
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Ambulance Rates Study 10
Personnel respond from six (6) strategically located fire stations to provide quick and effective response.
3.1.1 ANNUAL COST OF EMS SERVICES
The focus of this cost-of-service analysis was to reasonably estimate the total annual costs of providing ambulance services that can be recovered through fees for services. Table 2 presents the total cost-of- service analysis for the City’s Fire Department, segregated into the main service delivery programs:
TABLE 2. TOTAL FIRE DEPARTMENT SERVICE COSTS PER PROGRAM
As shown, the total cost of providing all Department services is approximately $36.3 million. EMS services are approximately $28.1 million, which is 79% of total Department costs.
EMS DIRECT LABOR COSTS
The amount of “Labor” costs shown in Table 2 above was established as follows.
Firefighters and paramedics are divided into 3 shifts working on a rotational schedule. Utilizing a constant staffing philosophy, each shift consists of 75 personnel ready to respond and provide emergency and non- emergency services any time of day .
According to the calls for service report, most calls for service responded to by the Department are EMS rather than suppression related.
• The two (2) BLS ambulances and four (4) paramedic ambulances in service are supported by five (5) paramedic fire engines and (1) truck company.
• There are three (3) reserve ambulances. Each time an ambulance responds to a call for service, a paramedic fire engine accompanies that ambulance to provide medically necessary support to the ambulance and personnel inside it.
• The City’s Standard of Coverage calls for the first paramedic on scene in the urban/suburban response areas in ten minutes and 30 seconds (10:30), and in the rural response areas in fourteen minutes and 30 seconds (14:30), with the goal of meeting this 90% of the time. • Each ambulance is staffed with two people, both are paramedic firefighters. • Each paramedic engine is staffed with three people: a captain, an engineer, and a firefighter.
All personnel on engines are paramedics.
Cost Element Fire Suppression Fire Inspection
Emergency
Medical Services
(EMS)
Disaster
Preparation TOTAL
Labor 1,977,858$ 1,071,484$ 20,706,221$ 147,485$ 23,903,048$ Recurring Non-Labor 1,391,331 193,968 2,590,026 21,922 4,197,247 Ambulance Replacement - - 254,266 - 254,266 Citywide Overhead 1,519,064 88,313 679,383 16,376 2,303,136 Department Admin 776,517 215,051 3,849,008 29,512 4,870,088 Department Total 5,664,770$ 1,568,816$ 28,078,904$ 215,295$ 35,527,785$ 12/10/2024 PH3 18 of 29
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Ambulance Rates Study 11
• All fire suppression staff (75 FTE) are certified at the paramedic level (ALS) and the BLS ambulance, while non-safety personnel are certified at the EMT level (12 FTE positions).
The following calls for service analysis from FY 2022/23 shows the breakdown of incidents EMS calls versus other types of calls.
TABLE 3. CALLS FOR SERVICE
Table 3 shows the City’s percentage of incidents for Emergency Medical Services is approximately 87% of all calls for service, while 13% are non-medical. Because the City accounts for salaries and benefit expenses for all paramedic personnel in two budgetary units, Emergency Medical Services and Fire Suppression, a method for allocating direct labor costs between the Department’s main service delivery programs is needed. To estimate the amount of salaries and benefit costs dedicated to providing EMS services, NBS used the calls for service data as a general means of allocating staff that are on ambulances and supporting paramedic engines.
OPERATING AND CAPITAL COSTS
Review of the City’s adopted expenditure budget for FY 2023/24 identified several on-going operating costs that are directly attributable to the provision of EMS services. These are shown in Table 2 as “recurring non-labor,” and further detailed in Table 4, below:
Type of
Incident
Assigned
Incidents
Percentage of
Incidents
Medical 14,115 87%
Other 2,116 13%
Grand Total 16,231 100%
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Ambulance Rates Study 12
TABLE 4. EMS OPERATING COSTS
Approximately $4 million are operating costs directly dedicated to providing Emergency Medical Services.
Operating costs include services and supplies needed to support operations, as well as the cost of replacing vehicles and equipment needed for service delivery which are shown as the “Replacement Capital > $5,000” expenditures toward the bottom of the list.
OVERHEAD COSTS
Several types of overhead costs are also considered in this analysis. Citywide Overhead costs include administrative services that support the Fire Department such as Finance, Human Resources, City Manager, Information Technology, etc. The City’s Finance Department provided an overhead cost allocation plan analysis, which for FY 2023/24 identifies $2.8 million in overhead costs attributable to the Fire Department, with approximately $679,000 attributable to EMS services.
Operating Cost Item FY 23/24 Budget
Contracts With Other Agencies 640,466$
Service Contract 289,768
Office Supplies 1,750
Operating Supplies 316,280
Tools/Furniture/Equipment 3,605
Training/Mileage/Conferences 1,030
Train Materials & Publications 4,378
Special Department Expense 1,034,366
Professional Memberships 265
Technology Purch & Services 16,280
Uniforms & Accessories 23,750
Equipment Maintenance/Services 8,000
Printing/Copying 500
Telephone 810
Wireless Connection 28,744
Replacement Capital > $5,000 1,049,964
Facility Rental 16,304
Insurance & Surety Costs 146,946
Information Technology Charges 376,669
EMS Total 3,959,875$
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TABLE 5. OVERHEAD COSTS
In addition to Citywide Overhead Costs, Fire Department Administration, Training, and Maintenance costs were also allocated to all Fire Department service areas, with EMS receiving approximately $3.8 million, as shown in Table 6.
TOTAL ANNUAL COST ALLOCATION SUMMARY
Based on the analysis completed for each attributable cost component described above, Table 6 summarizes the City’s total estimated annual cost of providing EMS services at $28.1 million. As described above, the total estimated cost of providing services includes all identifiable direct and indirect costs.
TABLE 6. TOTAL ANNUAL EMS COSTS
3.1.2 INDIVIDUAL FEE FOR SERVICE COSTS
To translate the total annual EMS costs established in Table 6 into individual costs per type of ambulance service, EMS costs were allocated to individual fee for service categories based on the average number of calls by type and the average amount of time required to service each type of call according to dispatch records.
Allocated Indirect/Support Services 2023-24
Adopted Budget
Citywide Overhead
Fire Administration 136,366$
Fire Training 32,945
Fire Maintenance 306,138
Fire Suppression 1,519,064
Fire Inspection 88,313
Emergency Medical Services 679,383
Disaster Preparedness 16,376
TOTAL CITYWIDE OVERHEAD COSTS 2,778,585$
Cost Element
Emergency
Medical Services
(EMS)
Labor 20,706,221$
Recurring Non-Labor 2,590,026
Ambulance Replacement 254,266
Citywide Overhead 679,383
Department Admin 3,849,008
Department Total 28,078,904$
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Utilizing calls for service data provided by the City’s dispatch system, a weighted distribution factor was derived by call time between Transports, Non-Transports, and Other Calls. Each time an ambulance responds to a call for service, a paramedic engine also accompanies that ambulance to provide medically necessary support. Therefore, service time must reflect the total number of personnel responding to each call, on average:
• Ambulance: Two-person crew consisting of Paramedic/Firefighters • Paramedic Engine: Three-person crew consisting of Captain, Engineer and Firefighter. Each staff member on the Engine are also Paramedics.
• Transports are defined as calls that consisted of a patient being transported to the hospital by ambulance. Transports last an average of approximately 97 minutes per call. • Non-Transports are defined as calls where treatment was administered on the scene, but the ambulance did not transport the patient to a hospital, also known as “Dry Run”. Dry runs last an average of approximately 26 minutes per call.
• Other Calls are defined as calls where no incident was found, which would be indicative of no treatment was administered on-scene and no transport was provided by ambulance. These calls last an average of 11 minutes and have no potential for recovery of costs through fees for ambulance services.
The cost-of-service analysis for individual ambulance services is shown in Table 7 below.
TABLE 7. AVERAGE TOTAL COST PER TYPE OF AMBULANCE SERVICE
Per the dispatch data, Table 7 shows the average annual distribution of effort required to service various types of Emergency Medical Services calls as 78% Transports, 17% Treatment Non-Transports, and 5% Other Calls. Applying the $28.8 million of costs shown in Table 6, the average cost of service per ambulance call is $3,629 for Transport, $981 for Treatment Non-Transports, and $432 for Other Calls.
3.2 Fee Establishment
The City’s current fee structure and fee amounts are shown in Table 8 on the following page. As discussed in Section 2.2.2 of this report, the Study’s process provided the opportunity to propose additions and deletions to the fee schedule, as well as to rename, reorganize, and clarify fees imposed.
In general, ambulance fee schedules tend to be standardized across local governments. Fee schedules typically contain the following types of fees for services:
Type of Ambulance
Service Total Calls Ambulance Engine Total Total -
Annual
%
Distribution
Average
Cost per
Service
Transport 6,057 3.23 4.84 8.06 48,835 78%3,629$ Non-Transports 4,771 0.87 1.31 2.18 10,401 17%981$ Other 3,287 0.38 0.58 0.96 3,153 5%432$ Total 14,115 62,388 100%
Average Service Time (hrs)
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• Transport Fees, which are typically delineated between ALS versus BLS transport services, and treatment without transport services. Fees for transport services also sometimes indicate different fee amounts for residents versus non-residents. • Add-on Charges, for services provided during transport that vary per incident, such as mileage, oxygen, medications, supplies, EKG, etc.
Vista’s transport fees are structured within the same standards seen in other agencies. NBS recommends the City publish all standard Add-on charges that it intends to bill for on a routine basis in the Master Fee Schedule.
3.3 Cost Recovery Evaluation
Table 8 shows the Total Cost of Service Per Activity calculated by the Study (full cost recovery fee amounts) as compared to the current fees charged by the City.
TABLE 8. CURRENT FEE EVALUATION AND PERFORMANCE
As shown, the City’s current transport fees recover between 16% and 47% of the total cost of providing each service. Add-on charges were not evaluated on a cost-per-service basis. As shown, the total cost of service per activity for each level of service is as follows:
EMERGENCY MEDICAL SERVICES and
AMBULANCE TRANSPORT
Base Charge-Advanced Life Support 1
Vista Resident flat 3,629$ 100%1,580$ 44% Vista Non-Resident flat 3,629$ 100%1,709$ 47% Base Charge-Advanced Life Support 2
Vista Resident flat 3,629$ 100%1,697$ 47% Vista Non-Resident flat 3,629$ 100%1,829$ 50% Base Charge-Basic Life Support
Vista Resident flat 3,629$ 100%1,000$ 28% Vista Non-Resident flat 3,629$ 100%1,117$ 31% Treatment and Release
Vista Resident flat 981$ 100%154$ 16% Vista Non-Resident flat 981$ 100%254$ 26%
ADD-ON CHARGES
EKG flat 20$
Medications flat Cost + 55%
Mileage per mile 27$
Oxygen flat 65$
Disp Supplies Level 1 flat 65$
Disp Supplies Level 2 flat 150$
Total Cost of
Service Per
Activity
Vista
Current Fee
Existing Cost
Recovery %
Cost
Recovery %Fee Description Fee Unit /
Type
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o The total cost of service per activity for ALS Support 1 Transports is $3,629, while the current fee is $1,580 for City residents, which yields a 44% recovery rate. The current fee is $1,709 for non-residents, which yields a 47% recovery rate. o The total cost of service per activity for ALS Support 2 Transports is $3,629, while the current fee is $1,697 for City residents, which yields a 47% recovery rate. The current fee is $1,829 for non-residents, which yields a 50% recovery rate. o The total cost of service per activity for BLS Transports is $3,629, while the current fee is $1,000 for City residents, which yields a 28% recovery rate. The current fee is $1,117 for non-residents, which yields a 31% recovery rate. o The total cost of service per activity for Non-Transports is $981, while the current fee is $154 for City residents, which yields a 16% recovery rate. The current fee is $254 for non-residents, which yields a 26% recovery rate.
3.3.1 RECOMMENDED FEES - POLICY APPROACH
The following table shows three options for establishing ALS Transport, BLS Transport, and Treatment and Release (Non-Transport) fees either at or below the 100% full cost of service fee amounts calculated through this Study.
• Option 1: Transport fees established at 100% full cost recovery; Add-on charges assumed at no change from current fee amounts
• Option 2: Transport fees and Add-on charges established at the average of the regional comparison
• Option 3: Transport fees at the average of the five agencies in the comparison; Add-on charges assumed at current cost
In addition to establishing updated fees for transport and add-on charges, the City wishes to apply a CPI index inflator annually to keep up with rising costs.
• Fees adjusted annually, beginning July 1, 2025, and each July 1st thereafter, by the percentage change in the Consumer Price Index (CPI) Series Title Medical Care in the U.S. City Average, All Urban Consumers, Not Seasonally Adjusted, as published by the U.S. Department of Labor, Bureau of Labor Statistics for the twelve (12) month period ending December 31 of the preceding calendar year.
• The CPI index inflator would need to be approved by City Council, adopted at a regularly scheduled City Council meeting to enact the increase.
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TABLE 9. POLICY OPTIONS
Using this approach to establish recommended fees for the Council’s consideration, the annual estimated billings for each policy option are illustrated in Table 10.
TABLE 10. BILLED VS COLLECTED
At current billing levels, the City would increase a nnual billing amounts from approximately $10.8 million, to up to $29.9 million at full cost recovery fee amounts. Once the collections rate of 33% is applied, the net increase in revenue collected ranges from an estimated $3.2 million to $9.8 million, depending on the policy option chosen. However, as discussed further in Section 3.3.2, the amount to which any adopted fee increases will affect City revenues is difficult to quantify.
EMERGENCY MEDICAL SERVICES and
AMBULANCE TRANSPORT
Base Charge-Advanced Life Support 1
Vista Resident flat 3,629$ 100%2,699$ 74%2,631$ 73%1,580$ 44% Vista Non-Resident flat 3,629$ 100%2,729$ 75%2,753$ 76%1,709$ 47% Base Charge-Advanced Life Support 2
Vista Resident flat 3,629$ 100%2,872$ 79%2,665$ 73%1,697$ 47% Vista Non-Resident flat 3,629$ 100%2,903$ 80%2,795$ 77%1,829$ 50% Base Charge-Basic Life Support
Vista Resident flat 3,629$ 100%2,083$ 57%2,581$ 71%1,000$ 28% Vista Non-Resident flat 3,629$ 100%2,108$ 58%2,705$ 75%1,117$ 31% Treatment and Release
Vista Resident flat 981$ 100%390$ 40%620$ 63%154$ 16% Vista Non-Resident flat 981$ 100%370$ 38%670$ 68%254$ 26%
ADD-ON CHARGES
EKG flat 28$ 34$ 20$
Medications flat Variable Variable Cost + 55%
Mileage per mile 41$ 24$ 27$ Oxygen flat 120$ 76$ 65$
Disp Supplies Level 1 flat Variable 88$ 65$ Disp Supplies Level 2 flat Variable 227$ 150$ Total Cost of
Service Per
Activity
Vista
Current Fee
Existing Cost
Recovery %
Cost
Recovery %
Regional Fee
Average
Average of the
Five
Comparison
Agencies
Selected
Cost
Recovery %
Cost
Recovery %Fee Description Fee Unit /
Type
Average Annual
Billings at Current
Fees
Option 1
-
100% Full Cost
Recovery Fee
Levels
Option 2
-
Regional Fee -
Average
Option 3
-
Average of the
Five Comparison
Agencies Selected
Billed $ 10,810,992 $ 29,884,973 $ 19,488,120 $ 20,931,927 Collected $ 3,240,784 $ 9,838,133 $ 6,415,489 $ 6,890,790 Net Collected Revenue
Increase $ 6,597,349 $ 3,174,705 $ 3,650,006 Estimated Annual Billings per Policy Option
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3.3.2 PAYER MIX
Understanding the City’s payer mix is an important consideration when setting final fee amounts because most bills for ambulance services do not result in full payment. For example, as discussed throughout this report, CMS sets limits, or “caps,” for how much a provider can be reimbursed for ambulance services.
CMS, however, does not regulate how much can be charged to private paying patients or commercial insurance companies. Individuals may have issues with their ability to pay the full fee amount, and commercial insurance companies may have their own limits and reimbursement policies. Actual reimbursements are based upon billing the patient for the medical service provided and dependent on whether the recipient of a bill has private or public insurance, or no insurance. There are four basic categories of reimbursements.
• Medicare – Primary health care coverage for people over the age of 65 • Medi-Cal – Component of the federal Medicaid program that is provided for qualified individuals and families
• Commercial Insurance – Benefits purchased independently, or provided by employers to employees
• Private Pay – For those without any form of medical insurance
The data in the following tables shows the City’s current payer mix based on financial class data and revenues reported by the City’s third-party biller, Wittman Enterprises LLC. This information may be useful in understanding the impact on actual reimbursements received after recommended fees are adopted.
TABLE 11. PAYER MIX – NUMBER OF TRANSPORTS
In Table 11, out of a total of 8,482 transports for FY 2022-23, Medicare is the largest category, representing 3,323 transports and 39.18% of the transports mix. Private Pay is the second largest, and Commercial Insurance and Medi-Cal categories are third and fourth largest.
In Table 12, the City’s total revenues received by reimbursement category (payer mix) are displayed for FY 2022-23. As shown, Commercial Insurance payers have the highest reimbursement rate, followed by Medi-Cal, Medicare, and Private Pay.
Category Number of
Transports
Percentage of
Transports
Medicare 3,323 39.18%
Medi-Cal 1,917 22.60%
Commercial Insurance 2,187 25.78%
Private Pay 1,055 12.44%
Totals 8,482 100.00%
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TABLE 12. PAYER MIX - TOTAL REVENUE
It is important to note that increasing ambulance transport fees and add -on charges does not necessarily translate to a total increase in revenues at the reimbursement/payor level. For example, due to the fee limits set by CMS, one should not expect the Collection Rate per transport to increase significantly from what is shown above. Further, private Pay is likely to not have any actual revenue collection. Out of all four payer categories, Commercial Insurance is the most likely to pay the highest reimbursement rate and the most likely to exhibit flexibility in its Collection Rate as compared to the other categories.
TABLE 13. PAYER MIX – REVENUE PROJECTIONS
Revenue projections based on the three different cost recovery levels are reflected in table 13. These projections are based on the assumption that gross percentage payment collected remains at approximately 33%. It is important to note that the City has been actively working to increase the gross percentage collected by capturing patient information at the scene. For example, the gross percentage collected between July 1, 2023, and December 31, 2023, reflects an 11-point increase to 43.94%.
Category Number of
Transports
Collection
Rate Revenue Percentage of
Revenue
Medicare 3,323 410$ 1,363,572$ 34.44% Medi-Cal 1,917 341$ 653,274$ 16.50% Commercial Insurance 2,187 849$ 1,856,077$ 46.87% Private Pay 1,055 82$ 86,822$ 2.19% Totals 8,482 3,959,745$
Category
Option 1
-
100% Full Cost
Recovery Fee
Levels
Option 2
-
Regional Fee
Average
Option 3
-
Average of the
Five Comparison
Agencies
Selected
Medicare 3,387,845$ 2,209,229$ 2,372,903$
Medi-Cal 215,058 215,058 215,058
Commercial Insurance 4,611,493 3,007,174 3,229,965 Private Pay 215,712 140,667 151,089 Totals 8,430,108$ 5,572,128$ 5,969,014$
Estimated Annual Revenues (Collected) per Policy
Option
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CONCLUSION
Based on the Cost-of-Service Analysis, Fee Establishment, and Cost Recovery Evaluation outcomes presented in this Study, the proposed schedule of fees for City Council’s consideration has been included in the City’s accompanying Staff Report.
As discussed throughout this report, the proposed fee schedule intends to improve the City’s recovery of costs incurred to provide individual services. The amount to which any adopted fee increases will affect City revenues is difficult to quantify. For the near-term, the City should not count on increased revenues to meet any specific expenditure plan. Experience with the revised fee amounts should be gained first before revenue projections are revised. However, unless there is some significant, long-term change in activity levels at the City, proposed fee amendments should enhance the City’s cost recovery performance, over time, providing it the ability to stretch other resources further for the benefit of the public at large.
Disclaimer: In preparing this report and the opinions and recommendations included herein, we relied on several principal assumptions and considerations regarding financial matters, conditions and events that may occur in the future. This information and assumptions, including the City’s budgets, time estimate data, and workload information from City staff, were provided by sources we believe to be reliable; however, we did not independently verify such information and assumptions. While we believe our use of such information and assumptions is reasonable for the purpose of this report, some assumptions will invariably not materialize as stated herein and may vary significantly due to unanticipated events and circumstances. Therefore, the actual results can be expected to vary from those projected to the extent that actual future conditions differ from those assumed by us or provided to us by others.
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PRIOR ACTIONS
On May 12, 2009, adopted City Council Resolution No. 2009-102, amending ambulance transport fees (Vote: 5-0)
On September 14, 2004, adopted City Council Resolution No. 2004-198, amending ambulance and emergency medical service response fees and charges (Vote: 5-0) On March 14, 1995, adopted City Council Resolution No. 95-24, approving fees and charges for ambulance and paramedic services (Vote: 4-1, Cole opposed) On September 3, 1968, adopted City Council Ordinance No. 68-36, providing for the establishment and maintenance of emergency ambulance service (Vote: 4:0, Smith absent) 12/10/2024 PH3 29 of 29
EXHIBIT 4
Vista Fire Rescue
Emergency Medical Services Fees
Setting Goals
and Objectives
History
Ambulance transport service fees were last amended in 2017.
•Public agencies must set fees based solely on costs to provide services, as they are prohibited from generating profits.
•A review/study of current emergency medical services
fees was necessary.
•Informal bids were obtained; NBS Government Finance
Group was the lowest responsive bidder and conducted
the study.⚬The study found the City of Vista spends $28.1 million annually to provide medical services to the
community.⚬The study recommended increasing fees to attempt to achieve full cost recovery.
Public Agency Emergency Medical Services Fees
•City of Carlsbad
•City of Chula Vista
•City of Coronado
•City of Escondido
•City of Oceanside
•City of Poway
Recent Full Cost Recovery Fee Adjustments Across
San Diego County
Despite billing our full rate, we only collect 33% of charges. This is based on our payer mix.
What is full cost recovery for emergency medical services fees? Payer Mix by Hospital Transports Payer Mix by Revenue Received
The study recommended an annual
Consumer Price Index (CPI)
adjustment.
Staff recommends an annual
adjustment based on CPI specifically
for the ambulance industry.
Emergency Medical Services
Fee Adjustments
What is the
impact to the
City of Vista
general fund?
•Currently, 76% of the Fire Department's
budget is allocated to delivering
emergency medical services.
•Current emergency medical services
fees recover only 12.4% of service
costs back to the general fund.
•The proposed fee adjustment would
increase cost recovery to 30% of
emergency medical services expenses.
Thank You