AshevilleCity - County Gov.Leslee KulbaLocal News: Asheville and Hendersonville

The MEDIC saga and government’s power to marginalize

The Buncombe County Commissioners finally heard the results of a study commissioned to determine whether or not MEDIC should be allowed to answer 911 calls. MEDIC is a private, for-profit ambulance company founded in 1982. Kermit Tolley and his wife, Sharon started the business with two Ford trucks and a passion for helping people. They continue to perform limited ambulance service, like transporting patients to dialysis, but they are not allowed to have radios that would link them to the county’s dispatchers, interoperability being a must-have for emergency services following the September 11 attacks.

Over a decade ago, as Tolley explained it, MEDIC cooperated with the county under a handshake agreement to help as needed on 911 calls. They covered calls when county ambulances were out of service, worked standby at large community events, and helped with 4WD rescue in inclement weather. But then, their call volume dropped 80%. When the county passed a new ordinance limiting the term of any franchise agreement to five years, MEDIC’s renewal application was denied.

This was because they had submitted a balance sheet instead of a detailed, audited financial statement. Other reasons given were nebulous. For example, the county’s EMS plan did not accommodate private ambulances; and the fire chiefs recommended against it because, among other things, the existence of a private company might confuse dispatchers.

Back in October, Kermit Tolley, Jr. told the commissioners MEDIC had since submitted all the necessary paperwork, and a response from the county seemed overdue. That led to the commissioners agreeing to grant a nonexclusive franchise extending to the unincorporated portions of the county, pending favorable findings by a study to be completed by Management Solutions for Emergency Services.

MEDIC was only asking for the privilege of getting patched in to the county’s 911 service to serve as backup. That is, if one department’s ambulance were to go out on call, MEDIC would position one of its ambulances closer to that area. The county already allows MEDIC to service downtown Asheville, which was characterized as having a significant indigent population that consumes vast amounts of emergency medical services without paying. The Tolleys accepted the opportunity gladly, because they want to serve.

The Report

Representing MSFES, consultant Keith Bost shared the report’s conclusion, “The data clearly shows that you do not have a need for [MEDIC] at this time, and should you see an increase in call volume, we would recommend you allow your current system to expand to its fullest extent first, before adding to it.”

Countywide, in 2017, 76.4% of ambulance calls were answered in less than eight minutes;77.7%, in no more than nine minutes. Then, in the 28753 zip code, average response times were 23 minutes and 46 seconds. The report noted a person can experience irreversible brain death within 4-6 minutes of the onset of cardiac arrest, and the chances of a person surviving cardiac arrest decrease 7%-10% with every passing minute without paramedic intervention. Resuscitation rarely works after 10 minutes.

The main issue, though, was money. Obviously, reimbursements exceed costs for services, because the report said if an outside agency’s ambulance were to siphon off calls, county departments would lose revenue. Revenue generation is one of the reasons why fire departments have wanted to go into the ambulance business – while MEDIC had ambulances but was not allowed to fully utilize them. Bost emphasized federal dollars that would flow to the county, Medicare and Medicaid payments comprising 53% of revenue from ambulance services rendered. Numbers were provided, but nothing was said about how much profit the county was netting from ambulance runs.

Some fire departments have already indicated they will be requesting higher tax rates this year. The report asked if the commissioners thought their constituents would support paying even higher fire district taxes to support losses in federal revenue that would result from the private sector acquiring a share of ambulance reimbursements. (You read that right.) It also asked if the commissioners were prepared to lay off staff should MEDIC prove more effective in positioning its vehicles for reducing response times.

While the report advised against giving MEDIC 911 access, it gave at least two pieces of advice in case the county decided otherwise. First, it suggested assigning MEDIC only to the places in the county with high response times. These places are rural and generate few calls, so acceptance of this deal could spell the final straw for MEDIC. Secondly, the report cautioned that if the county were to allow MEDIC access to 911 dispatchers, the parties should enter into a service agreement with minimum requirements, key performance indicators, and multiple inspections throughout the year.

What was worse, Bost had said an advantage of a nonprofit EMS is that, should they fail, their assets would be distributed to the community, a point citizen Don Yelton later corrected. Bost said should MEDIC fail, their assets would go to paying off corporate debt. He wanted terms in the contract to require MEDIC’s assets to be distributed to the community when they fail, an event the county holds the power to cause. The practice is generally referred to as “robbery.”

Commissioner Comments

The county, as a general rule, has been looking for public-private partnerships to save costs. The next week, the commissioners were scheduled to hear applications from parties seeking public funding for “strategic partnerships” that perform services the county would have to otherwise. This apparently didn’t translate to EMS service, in spite of recurring lamentations about how the county lacks the resources to deal with the opioid crisis.

The discussion that followed fairly led to the conclusion that ambulance reimbursements were a hefty example of “waste, fraud, and abuse” in the healthcare system. While the county is only paid for about 70% of EMS trips billed, the privilege of running an ambulance was, as Chair Brownie Newman described it, turf to be defended.

Fryar recalled how Buncombe County didn’t operate any ambulance services until it used its governmental powers to essentially decommission MEDIC. He said the county gave the fire departments extra cash, and the first thing they did was spend $161,000 on ambulances. The report indicated there was a surplus of ambulances in some departments while response times were not acceptable in other parts of the county. Then Fryar noted the county had replaced its ambulance fleet and purchased three new vehicles after data had been provided for the MSFES report.

The county runs fourteen ambulances, and MEDIC, Fryar said, runs almost as many. But, unlike county fire departments, where EMT’s either stay at the station or are volunteers on-call, MEDIC stations its responders in the ambulances to eliminate “couch time.” Many commented during the meeting about county ambulances driving past MEDIC vehicles while responding to calls.

“Tolley bought his ambulances. They pay tax on them,” said Fryar, “We get money off their buildings, so if you think I’m gonna cut them down, you’re wrong.” He then added, “You’re talking about cutting the legs out from under the fire departments? You cut them out from under [MEDIC].”

Yelton asked why rural Fairview needed a ladder truck. He said rather than giving the fire departments more money, the county should determine which fire departments are struggling to pay for their ambulances and license coverage for those districts to MEDIC. He also suggested putting ambulance service out to bid to see if the private sector could operate more efficiently.

Several calls were made for better data. Commissioner Joe Belcher, for example, said he had been under the impression the board had approved a study to evaluate MEDIC. The consultants did not even talk to MEDIC staff and instead analyzed the county.

Robert Pressley said he had been told 347 calls had been transferred to MEDIC since December because the county didn’t have the resources to respond. He asked how that had factored into the calculated response times, and Bost answered a different question.

Al Whitesides said it was unfair to compare Buncombe County to more youthful counties. “We are a retirement community,” he said, “I don’t want to see us worried about a few dollars and hurting the service that we’re giving our constituents, because I might be one of them.”

Pressley echoed. “Being an ex-racecar driver, you’re in accidents all the time. I sure didn’t want someone from outside the county coming to the racetrack with me laying there for a couple hours when you have somebody right there who’s available.” Later on, he reasoned, “There’s one thing we can do something about, and there’s one thing we can’t do something about. The one thing we can do something about is if we need to offset to help the fire tax, we can. We cannot bring them back to life if they’re not there in time.”

In a 4-3 vote – with Belcher, Fryar, Pressley, and Whitesides in favor – the commissioners directed staff consult stakeholders to draft a contract for MEDIC. Before deferring to staff, ideas were batted around about how to restrict this or that, restrictions, of course, running counter to any effort to reduce response times. No deadline was given for completing the contract.

Granted, there is no natural right to be in communication with 911 dispatchers, but 911 is public infrastructure used for the business MEDIC operates. To deprive a business of access not only legislates them to a greater level of inefficiency, it prevents public ambulance services from learning better strategies for reducing response times that competition could motivate. If MEDIC had a bad business model, it would fail of its own accord, without all the help it’s getting from government.

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