HomeMy WebLinkAboutAgenda - 04-01-1996 - X-B 1
ORANGE COUNTY
BOARD OF COMMISSIONERS
Action Agenda
I t em No x--'B
ACTION AGENDA ITEM ABSTRACT
Meeting Date: April 1, 1996
SUBJECT: EMS Service Delivery and Financing Proposal
-----------------------------------------------------------------------
DEPARTMENT Emergency Management PUBLIC HEARING YES NO x
-------------------------------
BUDGET AMENDMENT
REQUIRED YES NO x
-------------------------------- -------------------------------
ATTACHMENT(S) INFORMATION CONTACT
3/28/96 Report Nick Waters, x3030
3/14/96 Letter from SORS Chief TELEPHONE NUMBER
3/21/96 Letter from Medical Director Hillsborough 732-8181
Chapel Hill 968-4501
Mebane 227-2031
Durham 688-7331
-----------------------------------------------------------------------
PURPOSE: To receive a report on proposed changes to the delivery and
financing of Emergency Medical Service in Orange County.
BACKGROUND: As a followup to the three year EMS Strategic Planning
Process begun in 1991, the Resources Subcommittee of the EMS Advisory
Council has been meeting for about two years to discuss options for EMS
service delivery, and alternatives for financing a possible new
delivery model .
The attached report outlines the specifics of the EMS Resource
Subcommittee ' s recommendations, as modified by the full EMS Advisory
Council at their meeting on March 27, 1996 . Key components include:
provision of all initial responses to 911 EMS calls, by County
paramedics in initial response vehicles (IRVs) ; provision of all
emergency ambulance service by South Orange and Orange County Rescue
Squads; and financing through a special district tax, broad fee for
service, or some combination of both.
RECOMMENDATION: The Manager recommends that the Board receive the
report, and provide conceptual approval of the delivery model, along
with specific direction about the Board' s preferences for the financing
mechanism it wishes staff to pursue in developing the 1996-97 budget .
2 '
MEMORANDUM
TO: Orange County Board of Commissioners
FROM: Rod Visser, Assistant County Manager
Nick Waters, Director of Emergency Management
Jeanette Smith, Emergency Medical Services Director
SUBJECT: EMS Service Delivery and Financing Proposal
DATE: March 28, 1996
The following staff report discusses recommendations presented to the
Emergency Medical Services Advisory Council at its March 27 meeting,
concerning proposed changes in the current EMS service delivery and
financing models . Furthermore, it includes the preliminary
recommendations from the Council to the Board of Commissioners, based
on EMS Council deliberations at that March 27 meeting.
Council and staff hope that the Board of Commissioners will receive
this report at their regular meeting on April 1, and provide direction
to County staff, and the EMS Council, on a service delivery model and a
financing mechanism to be implemented as early as possible during 1996-
97 . It is our intention to ascertain those aspects of the EMS Council
recommendations to which the Board gives conceptual approval now, and
those aspects about which the Board needs additional information before
making a final decision.
Following receipt of the Board' s initial direction, staff will work
with the County Attorney on any relevant statutory aspects of the EMS
Council proposals . Staff plans to bring this item back for final
approval in May, so that the Board' s decisions on service delivery and
financing can be incorporated into the Manager' s Recommended Budget for
1996-97 .
In addition to County staff, the EMS Advisory Council Chair, the
Medical Director, and representatives of both the South Orange Rescue
Squad and Orange County Rescue Squad will be present at the April 1
meeting to respond to questions from the Board of Commissioners .
Background
As a followup to the three year EMS Strategic Planning Process begun in
1991, County staff and the Resources Subcommittee of the EMS Advisory
Council have been meeting for about two years to discuss options for
EMS service delivery, and alternatives for financing a possible new
delivery model .
The following brief report outlines the specifics of the EMS Council ' s
recommendations . Key components include : provision of all initial
responses to EMS calls by County paramedics in initial response
3
vehicles (IRVs) ; provision of all emergency ambulance service by the
two rescue squads; and financing through either fee for service, a
special district tax designed to finance most of the programs and
services of the Emergency Management Department, or some combination.
Description of Service Delivery Model
The Resources Subcommittee examined a number of different service
models, and several variations of the original models . The
recommendation received by the EMS Council from the subcommittee, and
approved unanimously by the Council, involves a service delivery model
with two distinct components.
The "Response/Assessment/Treatment" component would be provided around
the clock by 15-20 paramedics who have received intensive training and
are able to provide a higher level of service. This highly trained
cadre would consist primarily of the County' s current professional
paramedic staff. However, these positions and training would be
offered as well to volunteer paramedics able to meet the time demands
and training standards that will be placed on IRV paramedics . IRV
paramedics would be dispatched in response to 911 calls for EMS. One
paramedic would respond in an IRV and provide initial assessment of the
patient at the scene. Depending on the condition of the patient, the
IRV paramedic could: complete the call if the patient does not need or
want treatment; provide treatment at the scene and release the patient,
with advice to the patient of options (at the patient ' s discretion) of
possible followup treatment; or call for ambulance service if medically
indicated. In some cases, based on established protocols (e.g.
indications of chest pain) , there would be simultaneous dispatch of
IRV, first responder, and ambulance. The roles of first responders and
telecommunicators trained in the procedures of emergency medical
dispatch (EMD) would remain similar to their roles in the current
system.
The "Emergency Ambulance Service" component would be handled around the
clock by the two rescue squads, with South Orange initially providing
day-to-day management oversight of ambulance operations, but with an
eye to the possible long-term merger of the two rescue squads . The
Boards of Directors of both squads have voted to support this service
'delivery model, and to develop a joint task force to work out
implementation details . South Orange would plan to hire, if necessary,
temporary and/or permanent staff to provide ambulance coverage to
augment volunteers, particularly during weekday daylight hours.
We believe it is important to note the high level of support that the
County' s professional paramedic staff have indicated for the Initial
Response Vehicle program. They have noted high expectations that have
been created during the six month pilot IRV program conducted between
August 1995 and February 1996 . They believe that implementation of the
IRV program (through the Response/Assessment/Treatment component) will
allow top-notch, professional, high quality pre-hospital and out-of-
hospital care. Some of the advantages they cite, based on experience
during the pilot project, include : improved access of experienced
4 ,
paramedics to citizens (paramedics to be available for every call) ;
reduced medical liability due to the provision of an advanced paramedic
assessment for every patient; an implementation of Total Quality
Management concepts in EMS delivery by delegation of responsibilities
and sub-management in day-to-day activities; timely response of persons
qualified to effectively manage multi-casualty, high stress, and
unusually demanding scenes; and a potentially positive impact on
patient outcome through advanced training in medical and trauma care
delivery. We also note that implementation of this delivery model has
the potential to strengthen the working relationships and enhance the
cooperation between County EMS staff and squad volunteers .
The Orange County Medical Director also is highly supportive of the
initial response paramedic service delivery proposal (see attached
letter) .
Descriptions of Alternative Financing Mechanisms
The Resource Subcommittee examined many potential revenue sources
during its discussions . The Subcommittee did not achieve consensus
about any one financing mechanism, but there was significant support
for two specific options . Accordingly, the Subcommittee agreed to
present two distinct options for comment by the EMS Council and for
deliberation by the Board of Commissioners . These models are described
below.
Financing Option 1 The first mechanism would be based on a
combination of elective memberships and fee for service. Under this
mechanism, billing and collection would be administered by the Orange
County Tax Collector. Citizens could elect to purchase, for $50 per
year, a membership in the EMS system for them and all other dependent
members of their household. The membership fee would entitle members
to unlimited necessary emergency medical service (but not convalescent
service) for a year, with no additional out of pocket costs . However,
the Tax Collector would pursue collection of bills with third party
payers (e.g. insurance companies, Medicaid) .
,Financing Option 2 The second mechanism would be based on the
creation of a Countywide special district tax for EMS and rescue
'service that would cover all expenses for the Emergency Management
Department except those services already funded by a specific dedicated
revenue source (e.g. fire inspection covered by fees, or E911 service
covered by 50 cent subscriber charges on monthly telephone bills) . One
possible variation would be to include third party billing only of EMS
users. The thrust of the second mechanism is to ensure no additional
direct out-of-pocket expenses to Orange County residents for EMS.
EMS Council Discussions After reviewing the financing alternatives,
the Council made it clear that it does not support the idea of a
membership program to help finance the system. A common observation is
that an EMS membership program is extremely cumbersome and time
consuming to manage and that there is some question whether the cost of
administering it is an efficient use of resources . The Council voted
• . 5
to change the focus of Option 1 to the simpler concept of making "fee
for service" the basic financing mechanism of the EMS system. The
underlying philosophy of this approach would be that individual users
of the EMS system should be responsible for their own use of the
service if either treatment or transport is required. Membership fees
were seen under the revised option 1 as just one variation of basic
fees for service, if the Board of Commissioners seemed interested in
that approach. When the discussion of the Council ' s financing options
was put to a vote, revised Option 1 received no affirmative votes .
There was strong support among the Council for option 2 . It was noted
that there would be some legal review required for this option, as the
North Carolina Statutes impose a number of restrictions on the creation
and employment of special district taxes . For example, a county may
not create a special district tax that includes a town' s jurisdiction
unless the governing board of that town agrees to be a part of the
special district . If the towns in Orange County chose not to
participate in a special district tax, decisions would be required as
to how town residents would receive EMS service . Option 2 was restated
by the Council as the creation of a special district tax to cover all
Emergency Management Department and Rescue Squad costs (less those
services for which the County already has alternative dedicated revenue
sources) . There would be third party billing of all EMS users, and
full billing of all non-Orange County residents or out-of-district
residents. Option 2 received by far the largest support with 8
affirmative votes .
The Council decided that a third option should be offered, so Option 3
was created for consideration. This option would basically be a
combination of Options 1 and 2, use of a special district tax with a
broader application of EMS fee for service than that incorporated in
Option 2 . There was only 1 affirmative vote for this new option.
The two financing options proposed to the EMS Council were built on the
assumption that one objective of the approved financing mechanism would
be to minimize the amount of additional County funds required to
operate the EMS system in 1996-97, even if the basic service model we
are now using were to be continued through 1996-97 . It is important to
note the view of EMS management that even if the basic service model
remains the same next year, EMS would need approximately an additional
$150, 000 for FY1996-97 IF we are to try to maintain the same level of
service next year. That is primarily attributable to the increasing
pressure on County funding to make up for the increasing challenges
that the volunteers face in providing the necessary volunteer hours for
system staffing upon which the current service delivery model was
originally predicated.
System Financial Needs
County funding of the current EMS system is approximately $850, 000 per
year. Approximately $950, 000 in additional funding would be needed to
meet the objective of providing service under the new model . Including
funding of all operational needs of the two squads (which heretofore
have been covered primarily by donations to the squads) , the new
6
service model is estimated to cost approximately $1 . 8 million in 1996-
97 . In developing our estimates of additional revenue needed to run
the redesigned EMS system in 1996-97, we have been very conservative in
our assumptions on both the revenue and expense sides . If all of our
"worst case assumptions" proved true, the County could fall
approximately $300, 000 short of the goal of no increase in County
funding to implement the proposed redesigned EMS delivery model . That
figure should be tempered by the point that if the County were not to
significantly change the current basic service delivery model in 1996-
97, it could cost at least $150, 000 more than the current $850, 000
County allocation to fund the same level of service .
We are reasonably confident that in 1996-97, the goal of limiting
additional County general funds for the system can be realized. Some
of the "worst case" scenario assumptions we have built in at this time
include : 1) all hours of squad coverage are budgeted as if they would
have to be provided by squad paid staff (i .e. no volunteer hours) ; 2)
only. a 30% collection rate on EMS bills; 3) only an 8% participation
rate for memberships; and 4) purchase of all 4 new IRVs in 1996-97 to
replace the vehicles used during the QRV pilot project from August 1995
through February 1996 .
The proposed fee schedule is comparable to those in surrounding
jurisdictions we examined (Alamance, Durham, Guilford, Wake) . For
response and assessment only, there would be no charge. When a
response leads to treatment at the scene only, there would be a $100
charge. When both treatment and Basic Life support ambulance transport
are required, the total charge would be $250 . When both treatment and
Advanced Life Support ambulance transport are required, the total
charge would be $350 .
We should note that following the EMS Advisory Council discussions, the
information discussed above under this subsection will almost certainly
need to be revised. The fees cited above were based on a scenario
where there would be a fee for service and membership fee program. If
the Board of Commissioners decides to pursue a special district tax, or
some other model, staff will develop new cost estimates and revise
revenue projections to be brought back to the Board for final approval
in May.
RECOMMENDATIONS
Following are the specific recommendations of the EMS Advisory Council
to the Orange County Board of Commissioners :
1) That the Board of Commissioners provide conceptual approval of the
EMS service delivery model described above.
2) That the Board of Commissioners give conceptual approval to a
financing mechanism based on either Option 1, Option 2, Option 3 , or
some combination of both; furthermore, that the Board identify any
other potential revenue sources it may want the Resources Subcommittee
to explore prior to giving final approval to the financing mechanism to
which the Board gives preliminary approval . An objective of the
financing mechanism chosen is to minimize any increase that may be
necessary in County general funds for the EMS program.
3) That the Board of Commissioners adopt the underlying principle that
no one will be denied emergency medical service due to an inability to
pay.
4) That the Board of Commissioners approve a financing mechanism that
provides that the expense of all necessary personnel, operating, and
capital costs incurred by the two rescue squads in providing emergency
medical service will be covered by revenues received by the County for
EMS. This provision is intended to minimize the dependence of the
squads on fundraising that is currently conducted, and would also
provide for payment of existing fixed obligations (e .g. South Orange
building mortgage, Orange County Rescue Squad' s truck lease-purchase
payments) .
5) That County staff implement the service delivery and financing
changes approved by the Board of Commissioners as quickly as feasible
during the period July 1- December 31, 1996 .
6) That County staff, with objective input from the EMS Advisory
Council, undertake evaluation of the approved EMS system changes as
part of the 1997-98 Orange County budget development process . Specific
attention would be paid to any aspects of the changed EMS system that
do not meet the performance expectations of the revised service
delivery and financing models .
7) That the service delivery model chosen facilitate the ability of
both paid and volunteer individual paramedics to maintain their State
certification through affiliation with an Advanced Life Support
provider (Orange County) .
.8
SOUTH ORANGE EMS AND RESCUE SQUAD
P.O. Box 700 Carrboro, North Carolina 27510
March 14,1996
Nick Waters,Director
Orange County Emergency Management
P. O.Box 8181
Hillsboro,N.C. 27275
Dear Nick,
After our Board of Directors Meeting last night,we voted to accept Model 2 as our way to move
forward. Our Board consisted of 10 members: Ray deFriess,Bobby Green,Neil Batson,David Tollerton,
Lee Hammond,Celeste Cantrell,Jim Jones,Tom Sullivan,Jim Lehmann,and Wendy Myers. Our vote
was: 8-for, 1-opposed,and no abstentions. Ray deFriess, Chief,did not vote and will not vote except to
break a tie.
Pending our discussion with Orange County Rescue Squad regarding their participation and pending
acceptable financial arrangements the Board of Directors would like for South Orange EMS and Rescue
Squad to provide transportation coverage EMS 24 hours a day,7 days a week,for the whole entire county.
We also voted that we would need to hire several full time personnel and several part time personnel to
cover daytime slots. As we have previously talked,we still would want the County to handle the billing
for services.
The Board of Directors feels like this would be a successful step towards EMS coverage in our county.
With many details still in the works,the overall picture is one that we feel would be most beneficial to the
citizens of Orange County.
Sincerely,
i;
Ray d�eFriess,kief
South Orange EMS&Rescue
wbm
• 4Pyrn r,
w L
LIR0.1A
♦ s 1`L n
THE UNIVERSITY OF NORTH CAROLINA
AT
CHAPEL HILL
The School of Medicine The University of North Carolina at Chapel Hill
Department of Emergency Medicine CB#7594
Greg Mears,MD,FACEP Chapel Hill, NC 27599-7594
Head,Division of EMS Phone:(919)966-6440
Medical Director,Orange County FAX: (919)966-3049
e-mail: gdm @med.unc.edu
March 21, 1996
Jeanette Smith
Orange County EMS
1914 New Hope Church Road
Chapel Hill, NC 27514
Re: EMS Training Quality, Management and Performance
Dear Jeanette:
Looking back over my involvement the past three years with Orange County EMS,
there is one issue that continues to be a problem. It is very nice to have a system
that has such a large number of volunteers; but the problem is the large number of
participants who are active within the OCEMS System and maintaining continuing
education and quality of performance.
Most of the problem involves very limited patient contact. With Orange County being
a relatively rural type county, the number of patients each volunteer EMS personnel
is in contact with is very limited. Unfortunately, this makes it very difficult to stay
proficient in advanced life support skills, such as IV administration, intubation, and
acute care management. It is also very difficult to create a continuing education
program that allows paramedics and those with advanced skills to continue
expanding their fund of knowledge while maintaining the large number of lower level
advanced life support providers who are needing to learn and maintain the very basic
topics and issues.
My recommendation to the County is to continue forward with the plan to create an
initial response paramedic to be present at every patient evaluation. With the current
census and call volume under Orange County operations, this would significantly
reduce the number of highly trained personnel who would be required to have
advanced skills training and procedural confidence. This, therefore, would allow for
more one-on-one or small group training sessions for these more advanced
providers.
Jeanette Smith 10
March 21, 1996
Page 2
I also recommend we initiate a separate continuing education program for the lower
level advanced life support providers that would include more basic content. This
format would allow Orange County to provide the maximum care that the State
allows an EMS system to provide, as well as to create a much more standard quality
of care for to each citizen who contacts Orange County EMS, decreasing the legal
liability risk for both the County and the Medical Director. I feel that the overall
quality of care provided to the citizens of Orange County could be greatly improved.
Sincerely,
ffvJ
J
Greg Mears, MD, FACEP
Assistant Professor
Head, Division of EMS
Medical Director, Orange County