Re: [TEXAS_EMS] Who should do transfer calls?

January 29, 2007

Yes, we agree. You're 100% correct.

GG

>

> GENE....would have replied sooner but I was outside watching the stars

> align...

>

> Gene, I wholeheartedly agree with you. Not only does it provide extra

> funding but it guarantees that all patients in a jurisdiction receive the same

> response...a very big issue with me...and I believe, one of the dark secrets

of

> EMS in Texas.

>

> Here is an example of how this could work...you have a county service that

> has 2 ambulances on duty 24/7 and a third unit when personnel respond to a

> page to come back into the station. Also, in this town there are 2 private

> services that have 2 ambulances each. Their primary mission is doing

non-emergency

> transports both within the county and back and forth from the large regional

> medical facilities over 2 hours away. Not only is there enough work to keep

> these 4 private units working...but more than once or twice a day they also

> provide backup to the 911 agency.

>

> If the county service could do all the work not only would they make the

> money that are keeping the privates in business...that money would further

build

> and support the 911 public safety piece of the business. It's the elective

> surgery keeping the ED open....plus if my grandma falls in the nursing home

> and they call a 7 digit number they get the same caliber and type of response

> as your grandma does when she falls and you call 911.....

>

> Truly a marriage of the public safety and healthcare pieces...

>

> Wow...we agree??!!?? This feels so....odd, wrong...yet exciting???? Wow.

>

> Dudley

>

> [TEXAS_EMS] Who should do transfer calls?

>

> The current thread about extending extraordinary protections to private EMS

> providers has got me to thinking about the whole issue of public EMS vs.

> Private EMS.

>

> Let's set the stage for this little post I'm about to make:

>

> 1. Most 911 providers that are run by governmental units do not do patient

> transfers, leaving them to the private services.

>

> 2. Private services exist to make a profit.

>

> 3. Public EMS services usually require taxpayer subsidy to function, since

> fees for service do not generally cover the types of calls that come to an

> exclusive 911 provider.

>

> 4. If private services do transfers, it stands to reason that they do so to

> make money.

>

> 5. If a private service can make money doing transfers, why cannot a

> publicly owned and run service also make money from transfers?

>

> 6. If a 911 service operates at a deficit, yet allows private services to

> " skim the cream " and take the profit-making transfers, why should the public

> not demand that the public services take on the transfers and also make money,

> thus offsetting the losses from 911 service?

>

> 7. Why should publicly owned services give away the profits to private

> companies?

>

> I expect that I will be tarred, feathered and run out of town on a rail for

> even suggesting such a thing as that a public 911 service should also do the

> transfers. The folks in the FD who run 911 calls would likely want my head on

> a platter, and so would the private owners who wouldn't like to see their

> gravy train derailed.

>

> But as a taxpayer and also as an advocate of a comprehensive prehospital

> care system, it makes no sense to me that a city or county would take the

> nonpaying part of the business and give away the paying part.

>

> Anybody agree?

>

> Gene Gandy

>

> ____________ ________ ________ ________ ________ ________

> Check out the new AOL. Most comprehensive set of free safety and security

> tools, free access to millions of high-quality videos from across the web,

free

> AOL Mail and more.

>

January 29, 2007

> 1. Most 911 providers that are run by governmental units do not do patient

> > transfers, leaving them to the private services.

> >

> > 2. Private services exist to make a profit.

> >

> > 3. Public EMS services usually require taxpayer subsidy to function, since

> > fees for service do not generally cover the types of calls that come to an

> > exclusive 911 provider.

> >

> > 4. If private services do transfers, it stands to reason that they do so

> to

> > make money.

> >

> > 5. If a private service can make money doing transfers, why cannot a

> > publicly owned and run service also make money from transfers?

> >

> > 6. If a 911 service operates at a deficit, yet allows private services to

> > " skim the cream " and take the profit-making transfers, why should the

> public

> > not demand that the public services take on the transfers and also make

> money,

> > thus offsetting the losses from 911 service?

> >

> > 7. Why should publicly owned services give away the profits to private

> > companies?

>

Unfortunately, the finances of the transfers vs. 9-1-1 and public vs private

are not quite that simple.

Private services, like mine, that do primarily " transfers " are able to post a

profit because we intentionally operate a less expensive system very

specifically targeted for the non-emergency market. Said simply, 9-1-1

response is

considerably more expensive...you must have more infrastructure and " stuff " ,

better unit-hour and service-area coverage and generally break and/or use up a

lot more equipment and supplies. Add in the first responder and

communications costs, and you can easily see that 9-1-1 systems simply cost

more.

Transfers, contrary to what many people think, do NOT pay better. They

actually pay less, from most major payers. Medicare, for example, specifically

pays over 30% more in our region for an ALS " emergency " call than an ALS " non

emergency " call. However, with non-emergency calls you:

1. have more control over timing, including waiting if need be, to

minimize the unit hours you must have available at all times.

2. can pre-screen and pre-approve calls for payment, when appropriate.

3. can send just the precise level of transport capability needed.

Add to that the fact that you don't use as much stuff, and are less likely to

break anything, on NET calls, and you can squeeze a better margin from those

calls than you can with 9-1-1's.

In 9-1-1 systems, you generally are forced to approach everything with a " be

armed for bear, hope it turns out to be a squirrel " approach. Certainly

there is the opportunity to tailor responses, to some extent...but not nearly as

much as in the NET market. And you have no choice but to respond to every

request for service, no matter what the finances of that request turn out to be.

The problem with having the public entity do the NET's too is mixing the

dispatch and UM functions for different missions and having the flexibility to

vary response levels appropriately. There are certainly systems that can do

it...Dudley probably can, because he did it in a previous life. I did too.

But other systems would have a terrible time making that leap. Systems that

are committed to single-tier, all-paramedic units, for example, would

actually lose MORE money doing non-emergency transfers, since their costs would

be

the same regardless, but they would get paid less for those calls.

So before everybody tries to sign your 9-1-1 agency up to do the transfers,

it would behoove you to dig down in the finances a lot more. It certainly

might work well, but not without considerable planning and effort.

, BS, LP

President

Central Texas Regional EMS

office

www.centraltexasems.com

Faculty, Temple College EMS Professions

Member, Air Medical Committee, GETAC

January 29, 2007

Now, I listen to , because he knows what he is talking about. So we

must take his comments into careful consideration.

He has much more experience in the nuts and bolts of EMS management than I

do, and what he says merits careful consideration.

I will put some comments into his post below, not to argue with him, but to

ask further questions.

Gene

In a message dated 1/29/07 10:43:01 PM, DP EMS 500 writes:

>

> 1. Most 911 providers that are run by governmental units do not do patient

> > transfers, leaving them to the private services.

> >

> > 2. Private services exist to make a profit.

> >

> > 3. Public EMS services usually require taxpayer subsidy to function, since

> > fees for service do not generally cover the types of calls that come to an

> > exclusive 911 provider.

> >

> > 4. If private services do transfers, it stands to reason that they do so

> to

> > make money.

> >

> > 5. If a private service can make money doing transfers, why cannot a

> > publicly owned and run service also make money from transfers?

> >

> > 6. If a 911 service operates at a deficit, yet allows private services to

> > " skim the cream " and take the profit-making transfers, why should the

> public

> > not demand that the public services take on the transfers and also make

> money,

> > thus offsetting the losses from 911 service?

> >

> > 7. Why should publicly owned services give away the profits to private

> > companies?

>

> Unfortunately, the finances of the transfers vs. 9-1-1 and public vs private

> are not quite that simple.

>

Agree.

>

> Private services, like mine, that do primarily " transfers " are able to post

> a profit because we intentionally operate a less expensive system very

> specifically targeted for the non-emergency market. Said simply, 9-1-1

response is

> considerably more expensive...you must have more infrastructure and " stuff " ,

> better unit-hour and service-area coverage and generally break and/or use up

> a lot more equipment and supplies. Add in the first responder and

> communications costs, and you can easily see that 9-1-1 systems simply cost

more.

>

, can a municipality not operate a parallel system, based upon your

model, and do the same thing that you're doing, if they have the same sort of

astute management that you have?

Is there no " economy of scale " that could be used by a municipal service to

take advantage of the profits available from transfers while using the

infrastructure that's already in place?

>

> Transfers, contrary to what many people think, do NOT pay better. They

> actually pay less, from most major payers. Medicare, for example,

specifically

> pays over 30% more in our region for an ALS " emergency " call than an ALS " non

> emergency " call. However, with non-emergency calls you:

> 1. have more control over timing, including waiting if need be, to

> minimize the unit hours you must have available at all times.

> 2. can pre-screen and pre-approve calls for payment, when appropriate.

> 3. can send just the precise level of transport capability needed.

> Add to that the fact that you don't use as much stuff, and are less likely

> to break anything, on NET calls, and you can squeeze a better margin from

> those calls than you can with 9-1-1's.

>

Again, , why can't a municipality do the same thing through good

management? Where is it written that a 911 service must use the same trucks

and

crews to do the transfers? Why could a city not develop a municipal transfer

service modeled exactly like your business is?

>

> In 9-1-1 systems, you generally are forced to approach everything with a " be

> armed for bear, hope it turns out to be a squirrel " approach. Certainly

> there is the opportunity to tailor responses, to some extent...but not nearly

as

> much as in the NET market. And you have no choice but to respond to every

> request for service, no matter what the finances of that request turn out to

> be.

>

East Texas Medical Center Hospital EMS has done this for many years, quite

successfully. It has used " power trucks " to run transfers during the day, and

other methods for meeting the needs of the community in a variety of ways.

Although it is a Stoutian model service, the underlying philosophy of which I

fundamentally disagree, it has, in all its markets, successfully combined the

911 business with the transfer business.

> The problem with having the public entity do the NET's too is mixing the

> dispatch and UM functions for different missions and having the flexibility to

> vary response levels appropriately. There are certainly systems that can do

> it...Dudley probably can, because he did it in a previous life. I did too.

>

> But other systems would have a terrible time making that leap. Systems that

> are committed to single-tier, all-paramedic units, for example, would

> actually lose MORE money doing non-emergency transfers, since their costs

would be

> the same regardless, but they would get paid less for those calls.

>

Yep. You're right about that. But what does that say about system

management? What it says to me is that there is a plethora of incompetent

management in municipal EMS systems. Incompetent managers ought to be escorted

from

the building and sent down the road to work at Mcs.

The fire service model is fraught with incompetence. Very few big city fire

department managers have any business running an EMS service, but they're

entrenched. I can't do anything about that, if the people don't have sense

enough to squeal about it, and they generally don't.

The big fire department EMS services are generally a cruel joke. But there

are lots of suburban departments that are fire-service that are state of the

art.

>

> So before everybody tries to sign your 9-1-1 agency up to do the transfers,

> it would behoove you to dig down in the finances a lot more. It certainly

> might work well, but not without considerable planning and effort.

>

As usual, you're quite correct. But no business works today without

considerable planning and effort. I think we have the right to expect that our

municipal governmental employees will exercise the same kind of planning and

effort in running their programs that a private manager would. Municipal

employees get paid good salaries, have good benefits, and we have the right to

expect

them to produce good results.

Texas has lots of cities with " city managers. " The city manager form of

government is very popular in Texas, and city managers have lots of power.

Most

of them are abject idiots when it comes to fire, police, and EMS services.

They tend to be great at sewer, water, waste removal, street building, grant

farming, and all sorts of other things but public safety, but they're dolts at

public safety.

Unfortunately, Texas cities are generally not well managed. And that

paucity of good management most often impacts those services that produce the

greatest expenditures and the least income: public services.

However, the people get what they vote for, and they richly deserve what they

get.

Gene G.

>

> , BS, LP

> President

> Central Texas Regional EMS

> office

> www.centraltexasems.com

> Faculty, Temple College EMS Professions

> Member, Air Medical Committee, GETAC

>

January 29, 2007

GENE....would have replied sooner but I was outside watching the stars align...

Gene, I wholeheartedly agree with you. Not only does it provide extra funding

but it guarantees that all patients in a jurisdiction receive the same

response...a very big issue with me...and I believe, one of the dark secrets of

EMS in Texas.

Here is an example of how this could work...you have a county service that has 2

ambulances on duty 24/7 and a third unit when personnel respond to a page to

come back into the station. Also, in this town there are 2 private services

that have 2 ambulances each. Their primary mission is doing non-emergency

transports both within the county and back and forth from the large regional

medical facilities over 2 hours away. Not only is there enough work to keep

these 4 private units working...but more than once or twice a day they also

provide backup to the 911 agency.

If the county service could do all the work not only would they make the money

that are keeping the privates in business...that money would further build and

support the 911 public safety piece of the business. It's the elective surgery

keeping the ED open....plus if my grandma falls in the nursing home and they

call a 7 digit number they get the same caliber and type of response as your

grandma does when she falls and you call 911.....

Truly a marriage of the public safety and healthcare pieces...

Wow...we agree??!!?? This feels so....odd, wrong...yet exciting?????

Dudley

[TEXAS_EMS] Who should do transfer calls?

The current thread about extending extraordinary protections to private EMS

providers has got me to thinking about the whole issue of public EMS vs. Private

EMS.

Let's set the stage for this little post I'm about to make:

1. Most 911 providers that are run by governmental units do not do patient

transfers, leaving them to the private services.

2. Private services exist to make a profit.

3. Public EMS services usually require taxpayer subsidy to function, since fees

for service do not generally cover the types of calls that come to an exclusive

911 provider.

4. If private services do transfers, it stands to reason that they do so to

make money.

5. If a private service can make money doing transfers, why cannot a publicly

owned and run service also make money from transfers?

6. If a 911 service operates at a deficit, yet allows private services to " skim

the cream " and take the profit-making transfers, why should the public not

demand that the public services take on the transfers and also make money, thus

offsetting the losses from 911 service?

7. Why should publicly owned services give away the profits to private

companies?

I expect that I will be tarred, feathered and run out of town on a rail for even

suggesting such a thing as that a public 911 service should also do the

transfers. The folks in the FD who run 911 calls would likely want my head on a

platter, and so would the private owners who wouldn't like to see their gravy

train derailed.

But as a taxpayer and also as an advocate of a comprehensive prehospital care

system, it makes no sense to me that a city or county would take the nonpaying

part of the business and give away the paying part.

Anybody agree?

Gene Gandy

________________________________________________________________________

Check out the new AOL. Most comprehensive set of free safety and security

tools, free access to millions of high-quality videos from across the web, free

AOL Mail and more.

January 30, 2007

In a message dated 1/29/07 11:31:32 PM, Wegandy1938 writes:

>

> , can a municipality not operate a parallel system, based upon your

> model, and do the same thing that you're doing, if they have the same sort of

> astute management that you have?

>

> Is there no " economy of scale " that could be used by a municipal service to

> take advantage of the profits available from transfers while using the

> infrastructure that's already in place?>>

>

If by " astute " management, you mean trial-and-error, with lots of errors and

extensive use of pulling things outta my butt...then yes, they're welcome to

use the " astute " management that I use

Yes, public agencies can operate parallel systems and do well. But that's a

considerable adjustment to what gov't services typically do. Vance Riley in

did it for quite a while, but he found that there were real

challenges to having this " other " ambulance operation sorta mixed in, sorta

segregated

from the emergency system. They eventually got out of the NET business.

The Galveston EMS system did it too (maybe still does?)...running Galveston EMS

and Galveston Medical Transport as separate operational units.

>

> Transfers, contrary to what many people think, do NOT pay better. They

> actually pay less, from most major payers. Medicare, for example,

specifically

> pays over 30% more in our region for an ALS " emergency " call than an ALS " non

> emergency " call. However, with non-emergency calls you:

> 1. have more control over timing, including waiting if need be, to

> minimize the unit hours you must have available at all times.

> 2. can pre-screen and pre-approve calls for payment, when appropriate.

> 3. can send just the precise level of transport capability needed.

> Add to that the fact that you don't use as much stuff, and are less likely

> to break anything, on NET calls, and you can squeeze a better margin from

> those calls than you can with 9-1-1's.

>

> Again, , why can't a municipality do the same thing through good

> management? Where is it written that a 911 service must use the same trucks

and

> crews to do the transfers? Why could a city not develop a municipal transfer

> service modeled exactly like your business is? >>

>

As mentioned above, you could do it but it's just not easy. There are

significant cultural issues within the public departments to overcome too.... " we

didn't join this department to run TRANSFERS " (imagine spitting sound here)

>

> In 9-1-1 systems, you generally are forced to approach everything with a " be

> armed for bear, hope it turns out to be a squirrel " approach. Certainly

> there is the opportunity to tailor responses, to some extent...but not nearly

as

> much as in the NET market. And you have no choice but to respond to every

> request for service, no matter what the finances of that request turn out to

> be.

>

> East Texas Medical Center Hospital EMS has done this for many years, quite

> successfully. It has used " power trucks " to run transfers during the day, and

> other methods for meeting the needs of the community in a variety of ways.

> Although it is a Stoutian model service, the underlying philosophy of which I

> fundamentally disagree, it has, in all its markets, successfully combined

> the 911 business with the transfer business.

>

Yes, and we did at S & W too. We did ~65% 911 and 35% NET, and it worked well

operationally and financially. But we ran " split " crews (EMT/medic), a

semi-tiered system and did lots of truck rotations to try to keep the workload

evenly distributed. It required constant and active system management.

Overall, you're absolutely right Gene....it could be done, and probably even

SHOULD be done in some communities. But there's a reason that's you don't

see much of it...it requires changes to the " emergency " model that so many field

personnel and managers are stuck on. Inertia is a powerful force.

Great debate and discussion though. And I think this is the sort of

discussion that is helpful to a lot of people...a little opportunity to learn

about

finances of our business as well as explore some operational models.

Thanks,

, BS, LP

President

Central Texas Regional EMS

office

www.centraltexasems.com

Faculty, Temple College EMS Professions

Member, Air Medical Committee, GETAC

January 30, 2007

> Here in Calhoun County we do it all and want to keep it that way.

>

> Henry

>

And if I remember right, y'all always have done so, haven't you? I remember

when my friend Louis worked there back in, I believe, the year a.d.

1857 or so, y'all did NET's as well as 9-1-1.

More than likely, the long-standing tradition of " doing it all " is part of

your culture, and therefore works relatively seamlessly.

Not so for many, probably most, public agencies.

Good for y'all!

, BS, LP

President

Central Texas Regional EMS

office

www.centraltexasems.com

Faculty, Temple College EMS Professions

Member, Air Medical Committee, GETAC

January 30, 2007

The private EMS/transfer sector has taken a giant leap forward with

...

-MH

>>> 1/29/2007 10:43 pm >>>

> 1. Most 911 providers that are run by governmental units do not do

patient

> > transfers, leaving them to the private services.

> >

> > 2. Private services exist to make a profit.

> >

> > 3. Public EMS services usually require taxpayer subsidy to

function, since

> > fees for service do not generally cover the types of calls that

come to an

> > exclusive 911 provider.

> >

> > 4. If private services do transfers, it stands to reason that they

do so

> to

> > make money.

> >

> > 5. If a private service can make money doing transfers, why cannot

a

> > publicly owned and run service also make money from transfers?

> >

> > 6. If a 911 service operates at a deficit, yet allows private

services to

> > " skim the cream " and take the profit-making transfers, why should

the

> public

> > not demand that the public services take on the transfers and also

make

> money,

> > thus offsetting the losses from 911 service?

> >

> > 7. Why should publicly owned services give away the profits to

private

> > companies?

>

Unfortunately, the finances of the transfers vs. 9-1-1 and public vs

private

are not quite that simple.

Private services, like mine, that do primarily " transfers " are able to

post a

profit because we intentionally operate a less expensive system very

specifically targeted for the non-emergency market. Said simply,

9-1-1 response is

considerably more expensive...you must have more infrastructure and

" stuff " ,

better unit-hour and service-area coverage and generally break and/or

use up a

lot more equipment and supplies. Add in the first responder and

communications costs, and you can easily see that 9-1-1 systems simply

cost more.

Transfers, contrary to what many people think, do NOT pay better.

They

actually pay less, from most major payers. Medicare, for example,

specifically

pays over 30% more in our region for an ALS " emergency " call than an

ALS " non

emergency " call. However, with non-emergency calls you:

1. have more control over timing, including waiting if need be,

to

minimize the unit hours you must have available at all times.

2. can pre-screen and pre-approve calls for payment, when

appropriate.

3. can send just the precise level of transport capability

needed.

Add to that the fact that you don't use as much stuff, and are less

likely to

break anything, on NET calls, and you can squeeze a better margin from

those

calls than you can with 9-1-1's.

In 9-1-1 systems, you generally are forced to approach everything with

a " be

armed for bear, hope it turns out to be a squirrel " approach.

Certainly

there is the opportunity to tailor responses, to some extent...but not

nearly as

much as in the NET market. And you have no choice but to respond to

every

request for service, no matter what the finances of that request turn

out to be.

The problem with having the public entity do the NET's too is mixing

the

dispatch and UM functions for different missions and having the

flexibility to

vary response levels appropriately. There are certainly systems that

can do

it...Dudley probably can, because he did it in a previous life. I did

too.

But other systems would have a terrible time making that leap.

Systems that

are committed to single-tier, all-paramedic units, for example, would

actually lose MORE money doing non-emergency transfers, since their

costs would be

the same regardless, but they would get paid less for those calls.

So before everybody tries to sign your 9-1-1 agency up to do the

transfers,

it would behoove you to dig down in the finances a lot more. It

certainly

might work well, but not without considerable planning and effort.

, BS, LP

President

Central Texas Regional EMS

office

www.centraltexasems.com

Faculty, Temple College EMS Professions