Minutes for November 5 2018

Facilitator Chris Thomas opened with introductions around the room.

Chris asked the group to consider the meeting notes from the 10/15 meeting, updated with corrections. Were the corrections correct? Aaron Abbot (REDCOM) indicated the concerns he raised were addressed in the document. Chris asked the group if any corrections were needed to the 10/29 meeting notes and no objections to the provided version were raised.

Discussion turned to the contract extension with AMR, and the status of that agreement. Bryan Cleaver (CVEMSA) reported DHS is working through a Fiscal analysis of current contractor to determine if the requested 20% increase is (or is not) reasonable. Bryan felt the amendment could be ready to go to the Board in 2-4 weeks, but should know more by the 19th of November. Discussion on lead times needed for scheduling Board items; six weeks at CAO with additional time required at the Department level.

Kurt Henke, (AP Triton, California Fire Chief’s Association) asked if the audit would be a public record. Kurt pointed out the fiscal report provided by AMR does not have information about inter-facility transport revenue vs. 911 calls.

Discussion on the work that Bryan was doing to reformat the spreadsheet and the goal to distribute that to stakeholders this week.

System Capacity

Chris moved the group to the topic of system capacity, asking stakeholders to consider what kinds of things they felt should be in the ordinance on that topic. Steve Akre (Sonoma Valley Fire Rescue Authority) pointed out public providers are not able to collect enough revenue to break even. Private providers cannot make enough to continue to serve rural areas, and public providers need to pick up those areas and usually serve them at a loss. Steve A. felt the ordinance should acknowledge rural public agencies providing ambulance service, and there needs to be to discussion about standup costs that are facing those providing service in those areas.

Steve Herzberg (BBFPD, EMCC Dist.5) stated ambulance revenue does not cover half the cost of the ambulance service in Bodega Bay. Ordinance or RFP should address county responsibility to provide service and the fact that public or private rural providers do not get help from county to provide this service. Support needs to be part of the system and built into the system. Steve H. went on to say that case law explores the concept that the county is responsible, in a narrow view, to provide transport care for indigent individuals, and in a broader view, to provide full prehospital care for all. Steve H. asked for help to subsidize the rural providers. Steve H. felt the available revenue in the system should be redistributed to support the entire county system. Currently, the City of Santa Rosa gets more than rural communities like Cazadero, Guerneville or Bodega Bay. How can the resources work for the entire county?

Chris Thomas pointed out decisions regarding allocation of funding reside with the Board of Supervisors rather than with the LEMSA. Chris asked if the stakeholder group wanted to take up the discussion for equality of care, and quality of care across the county. Considering for example, the number of resources available in different areas around the County and time it takes to gets those resources to where they are needed.

Kurt H. talked about reallocation of economic resources to rural providers. By ordinance, after evaluating the economics of the system, what can be assigned to more rural areas and supplement those areas. Looking at the revenue system-wide and look at dollars available to supplement the rural areas. Chris asked for clarification on the QAF; new federal money available per recent legislation.

Mark Heine (Windsor, Rincon Valley FPD) cautioned the group to be careful with use of the terminology “quality of care”. Perhaps instead describing the issue as a disparity in system surge capacity. The intent to avoid pulling rural resources into the core area.

Bryan Cleaver asked if the group was feeling comfortable about having an open conversation on system design and redesign with the assumption that the conversation and open brainstorming for the system as a whole would be without an agenda for a particular result. The purpose being to clarify stakeholder desire in the county to consider a single county-wide EOA for Sonoma County. Holder of single EOA could be a public or private entity which then contracts with public or private agencies to serve other areas. All agencies use the same fee structure across the County. Bryan asked if the group was able to look at that level of system as a potential solution. Steve Akre stated Sonoma Valley would not be not able to look at that supporting that now, the ambulance service model is integrated into the agency budget, unless there is another way to maintain the agency. Bryan shared a concept using Bodega Bay example. A Countywide EOA provider could meet obligations to provide service by Subcontracting with BBFPD and filling a funding gap. The District then benefits from the subsidy and the EOA agency can meet obligations more efficiently than staffing an ambulance on their own.

Maybe another way to make this happen. Mark H. felt a single EOA may not be able to do it. Mark encouraged the group to look at all the other options; potentially an answer lies in a middle ground approach.

Steve Akre opined that a single rate for ambulance services across the county may be beneficial for all. Steve Herzberg commented on the value of cross-trained crews in rural areas, stressing greater need in rural areas over urban areas. Steve felt the private providers are not equal in this regard. Steve H. also wants to hear more about fixed countywide rates. Jeff Schach (Petaluma Fire Department) expressing his views as a 1797.201 provider agency, would like to look at another way of collaboration instead of subcontracting with an EOA. One EOA for the county? No, but maybe there are other ways to look at systems that may work.

Bryan Cleaver proposed agreeing on a holistic approach for the County focusing on the organization of the EOA. Competitive bid for all but 201 areas. Single provider responsible entity for the contract requirements, but may subcontract or partner with existing agencies.

Kurt Henke felt the County could contract with another public agency as the single entity which would then contract with areas that need coverage. Kurt suggested setting an overall rate structure for private and public providers, which would build a system that is efficient while ensuring profitability in the range of 12-15% .

Mike Williams (The Abaris Group) suggested the County could use the RFP process to encourage submission of creative models. To flesh out ideas. Mike felt this was a process done in other areas.

Bryan Cleaver suggested a county contract might go to bid for provider in sections, and have the provision that the vendor will subcontract with 1797.201 in those areas that have providers as part of the competitive process. Contract could also specify that for life of contract the 201 agency retains the right to exit the arrangement and revert to a previous status as an independent provider. Bryan asked if there was a way to look at this model for our county.

Jeff Schach talked about defining unit hour cost for each provider public or private. You use Petaluma for this area and this is the associated cost.

Mark Bramfitt (LAFCO) pointed out the possibility of change within the public agency structure, and the stance towards participation of a given agency may change based on fiscal circumstances.

Steve Herzberg stated that the concern should be focused on patient care first, and then how to maintain that care and the service providing it. Steve also pointed out transport services subsidize the rescue services the fire-based providers deliver. Steve noted some improvement in this idea of shifting resources. Steve also expressed that for a full county EOA, 201s are not interested. Steve went on to state BBFPD is a 201 entity, irrespective of a legal dispute.

Kurt Henke felt the wealth in system should protect those who cannot generate their own revenue.

Bryan Cleaver felt there was room to support cross-role training and education for rural agencies. Provider X provides billing services for all, as well as training and education. Bucket of available revenue based on rates paid by commercial insurers; $4000 ambulance rates are paid by few private payors. Set rates high enough to run the system. If county sets rates an insufficient level, then public providers should go to their councils and boards to set higher rates to ensure service.

Steve Herzberg stated he was less concerned about redistribution of money. BBFPD does bring in money for tourism and those funds are redistributed to other county areas. Steve made the point that there is a variability in the cost of providing services in different areas. Distance, factors like cliffs, ocean increase cost of providing services based on location.

Steve felt the increased demand on resources should be included in recommendations to Board for recovering cost of doing business.

Bill Sugiyama (Falck Inc.) asked if the County would be open to contracting with a research firm to construct simulations to compare various models. Bill felt there were companies that could do this work based on other models. Bryan Cleaver felt the problem might not be with a level of commitment to find a model, but with the cost, as likely it would be an expensive study.

Jason Clopton with RRFPD is currently doing analysis for cost/revenue in whole EMS system. Jason needs data from County on the EOA provider. Jason reports all other providers are participating. Steve Herzberg mentioned the revenue issue is complex; low rates are not the answer and return on revenue is problem.

Kurt Henke advised the priority is to know the value of the revenue in the system. Kurt felt the important points for inclusion into the ordinance are the details for defining system value and the frequency of the assessment based on those metrics.

Chris Thomas felt a sub group to do the cost analysis is warranted and wondered if 2 months for fiscal analysis would be sufficient. Bryan Cleaver felt the level of system redesign has ordinance implications, and maybe the ordinance should be revised afterwards, rather than before.

Discussion on retaining flexibility within the ordinance to accommodate different ideas for system construction in an EOA

Surge Capacity

Steve Akre talked about challenges: Steve’s perspective was that local community providers are built to serve communities with low call volume. Those entities are acting as support for a high-demand portion of the county. The high demand area, the EOA, reaches the need for support more often due to low staffing levels. Steve feels the system should increase capacity when there is a need. There was discussion on defining “surge” as potentially over 30% of normal, but no agreed upon metric was created. Discussion was held on inter-facility transfer calls and impact on surge capacity.

One suggestion was to set a base level of coverage in ordinance, then address if surge is over a certain level than standards and goals set in ordinance apply.

Steve Herzberg talked about BBFPD ambulance as the only resource in the rural community leaving the coast to support the core. Steve concerned about the level of minimum coverage for residents. Steve feels Inter-facility transfer calls should be the concern of the EOA provider and not affect the coverage on the coast. Steve was open to emergency response to MCIs

Bryan Cleaver talked about addressing the issue in a county system status management plan. Ordinance should require a county-wide SSP updated regularly. DHS Epi Lucinda Gardener’s work is expected to be complete next week and that data will be key to understanding the problem. Bryan talked about the way SSPs work; instead of considering surge, the plan considers levels of availability. In a perfectly balanced system, no extra ambulances would be available but all responses would be on time. If a provider is doing IFT work, those are the surge capacity ambulances. The world is imperfect and the system doesn’t allow running at level 0; too many ambulances in wall times at the hospital.

The question developed by the discussion was does surge capacity need to be addressed in the ordinance?

Dean Anderson (AMR/SLS) pointed out the EOA agreement covers 911 calls and also all the ALS transfer calls. Both ALS and 911 calls are treated the same. Although the priority is on the 911 system calls, patients need to be moved, some due to critical need, and there still are wall times to consider.

Bob Norrbom (SVFRA) asked to address the level 0 issue, because we need to add units to this system.

Bryan Cleaver responded explaining a level 0 event results in a penalty. The current system does pull in mutual aid from the system around the core. That has the effect of increasing call volume for other providers while helping the core.

Minutes for November 5 2018

System Capacity

Surge Capacity

Other Topics to Consider