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Changes to EMS Service:
Is Full Dialogue Happening?
During the time of year when the Athens-
Ctarke County (ACC) government formulates
its budget for the coming fiscal year—and
in a year when Mayor Davison has proposed
the first millage rate hike in many years in
order to keep pace with rising costs across
the board—there's been something of a
background conversa
tion going on about an
entirely new expense
that the local govern
ment might, at some
point, be compelled to
take on: some or all of
the cost of providing
emergency medical ser
vices (i.e., ambulance
services) to local citizens. The conversation—
as most of the people involved frequently
refer to it—began in February, when a group
of administrators from both Athens Regional
Medical Center (ARMC) and St. Mary's hospi
tal went together to Mayor Davison and ACC
Manager Alan Reddish to, in the words of
ARMC spokeswoman Elaine Cook, "begin the
discussion."
That meeting served primarily as a signal
to the ACC officials that, for financial reasons,
the hospitals needed to begin exploring their
options insofar as changing the structure of
the emergency medical services (EMS) provi
sion goes. One of those options, of course,
would be for the local government to get into
the EMS business, either through helping to
subsidize the hospitals' continued provision of
the service, or by taking over the service com
pletely (and possibly incorporating it into the
fire department), as some municipalities have.
By all accounts, that initial conversation was
just that—initial—and it didn't necessarily
get very far, perhaps
mostly because of
the grim financial
picture of emergency
medical services in
the Athens-Clarke
and Oconee Counties
at the present time:
ARMC and St. Mary's
administrators, who
are working together closely on the EMS issue,
estimate their combined annual losses in
providing EMS to be near $2.5 million at this
point.
"Our response," Reddish says, regarding
that initial February conversation, "was that
it's a little odd that we'd be asked to take
[on] a service that was already running at a
deficit." Why has the EMS business become
such a losing proposition, financially speak
ing? In part because of rising costs in health
care in general, and because of basic rising
costs in areas-like fuel. Historically (that is,
in the last 40 years or so in Athens, since
hospitals took it over from funeral homes),
hospitals have supported EMS and provided
it as a part of their services, despite it often
not operating at a profit. Far more acute,
though, is a massive ongoing deficit—just
like that experienced regularly by doctors—in
reimbursements from federal health coverage
programs to ambulance services in general.
"The cuts in reimbursements for emergency
medical services, really from Medicaid and
Medicare, have been the problem," says St.
Mary's hospital spokesman Avery McClean.
"Those reimbursements are going down while
your costs are going up, so that's not a good
formula." Those "significant cuts in reim
bursements,* ARMC's
Cook says, have been
particularly large in the
last five years, making
the business of running
ambulances less and
less sustainable with
each passing year. There
is, of course, a third
option besides local
government subsidies or a government-based
service: contracting with a private company to
provide the service. All three set-ups appear in
communities across the state (while entirely
hospital-based and -funded service like
that presently in Athens is, apparently, rare
nowadays).
SEEKING THE BEST ROUTE
According to Cook, plenty of hospitals have
switched to contracting with private, for-profit
companies for ambulance service "with great
success." She cites major hospitals in Georgia
cities like Columbus and Macon, and says that
they've had "very good experiences" with the
larger private services—those being the only
ones that local hospitals would entertain con
tracting with.
But Sam Rafal, a local schoolteacher who
has been a certified emergency medical tech
nician for 20 years and works as such (not
for pay) from time to time as the need arises,
says it's worth mak
ing a full examina
tion of the level of
care—as well as the
prospect of a need
for subsidies—that
Athens could expect
with a for-profit EMS
company. If the hos
pitals can't run the
services without massive deficits, he asks, how
could a for-profit private company make it
work while maintaining the same level of care
that Athens currently enjoys?
That's one point on which hospital admin
istrators, Athens-Clarke officials and Rafal—as
well as local paramedic David Brooks—all
agree: the level of service and quality of care
in Athens and Oconee counties presently
are very high. All agree, also, that keeping
the same level of service in the future is a
must. "But among those," says ACC District 5
Commissioner David Lynn, "there's a difference
of opinion." Brooks, for example, approaches
the issue from the perspective of someone
who currently runs a long-distance medical
transportation company (which, he says, does
business with neither local hospital). He also
has worked as a paramedic under all three
potential arrangements. In the 1980s and
early '90s, he was a paramedic at St. Mary’s;
then he was a paramedic for Gwinnett County,
which funds EMS completely and includes
it in its fire department. Then, in the late
'90s, Brooks worked for a for-profit company
that, he says—in a nightmare scenario for a
local government—took over EMS in Catoosa
County, GA only to very quickly ask for a large
government subsidy. In the end, a neighboring
county's hospital took over Catoosa's cover
age. And, Brooks argues, for-profit companies
often don't have the high level of training and
employee recruitment
as hospital and gov
ernment services do,
nor the cutting-edge,
expensive equipment
that's as new as theirs:
"You can't look at two
ambulances and say,
'Well, it's a licensed ambulance from [the state
Department of Human Resources]; everything's
the same.' And they're not," Brooks says.
Even if a situation like the Catoosa County
tale that Brooks warns of is rare, though, it
remains unclear whether a for-profit EMS com
pany operating in Athens-Clarke and Oconee
counties would require a subsidy in order to
maintain the area's current level of service or
not. And while Rafal is doubtful of the lat
ter, his primary goal, by far, in taking action
on the issue is to encourage a conversation
that pursues a clear understanding among all
parties.
ANY REAL DIALOGUE?
"We may lose our hospital-based service
without even having had a constructive dis
cussion between the hospitals and the county
commission," he says. (Hence, simply foster
ing a full dialogue is the purpose of an online
petition Rafal has created; interested citizens
can email him at srafal@bellsouth.net to learn
more.) Via a "construc
tive discussion," Rafal
hopes the Athens-Clarke
and Oconee governments
might at least assess
what options might
be most cost-effective
(assuming that they will
have to pitch in), ranging
from subsidizing hospi
tals' continued service to the very expensive
prospect of taking over the services. He even
suggests an independent audit to determine
which costs associated with EMS are neces
sary, and which might be flexible. Meanwhile,
hospital administrators are keeping in mind
the now jittery but dearly-held—and, by all
accounts, first-rate—staffers in their EMS pro
grams, a motivation to work towards a resolu
tion that at least gives those employees a
clear picture of their future. Also, some accuse
interested citizens of having a fihancial self
interest in the outcome of the debate, though
Rafal and Brooks insist they have none.
And with the ACC Mayor and Commission
ready soon to adopt a budget that's draw
ing fire from homeowners upset with tax
increases, the idea of either taking over or
subsidizing a deficit-prone service—one which
hospitals historically ran, and which has been
all but abandoned, financially speaking, by
federal government programs—is obviously
unappealing. Still,
while Reddish pon
ders a tight budget
and awaits further
news from hospital
administrators—who
simultaneously are
exploring all options
and preparing to look at bids from for-profit
companies this summer—the larger question
of what services belong in the government
realm may go unaddressed.
The hospitals, Commissioner Lynn says,
"haven't approached the commission at all; we
haven't had a discussion in a formal sense."
Neither he nor Commissioner Andy Herod, who
is also interested in the issue, is particularly
up to speed on details of the prucess at this
point, since the formal discussion Lynn men
tions hasn't taken place.
"If it's a market failure," Lynn says, "then
that's a proper role, for local government to
provide literally a life-or-death service." He
adds, "Something tells me in the long term
this is going to require stronger local govern
ment participation than we're seeing now." In
that case, he says, he'd want to explore ways
to keep costs down, perhaps by creating some
kind of regional EMS system, for example. He
notes too that approaches like Gwinnett's,
with EMS inside the county fire department,
might make sense. Changes to that system
were common in the '90s,
he says. And by way of
background, Lynn says,
fire suppression calls have
gone down with changes
in building technology in
recent years, while medi
cal emergency calls have
gone up. "My gut reaction
is one day Clarke will
have to take over that service, like they have
in Jackson County, Gwinnett County..."
Lynn adds, "In the long run, this is a
discussion we need to be having." Rafal's
concern is that, with hospitals ready to stop
the financial bleeding, a change in policy may
be made without elected officials ever having
that discussion. "It's a lot of money," he says,
"but it may end up being more money if we
don't talk."
Ben Emanuel benSflagpole.com
“The cuts in reimbursements
for emergency medical
services, really from
Medicaid and Medicare,
have been the problem.”
“We may lose our hospital-based
service without even having
had a constructive discussion
between the hospitals and the
county commission.”
“If it’s a market failure, then
that’s a proper role, for local
government to provide literally
a life-or-death service.”
“Something tells me in the
long term this is going
to require stronger local
government participation
than we’re seeing now.”
NEWS & FEATURES
6 FLAGPOLE.COM • MAY 7. 2008