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Critical Condition in Emergency Response

Government barriers keep private ambulances from serving public

Marc Pickard is clearly frustrated as he explains why a man who suffered a stroke last week did not receive faster medical attention. Pickard is the training director for Convalescent Transport, a private ambulance company in North Carolina’s Lenoir County. He notes that — even though his company sits across the street from the stroke victim’s house — county law prevented a Convalescent Transport ambulance from responding. Instead, the man had to wait for a county ambulance. This Monday he died.

Although perhaps only an autopsy can settle the matter, Pickard can’t help but wonder whether the man would have survived if Convalescent Transport had been allowed to respond. Pickard is frustrated, but not surprised. From his office Pickard can eavesdrop on the county’s emergency dispatch system. He said it often takes more than 10 minutes for an ambulance to arrive at Meadows North retirement home, which is also across the street from Convalescent Transport headquarters. But the county forbids Convalescent Transport from responding to emergency calls, even calls from across the street.

“It can take the county as long as 12 minutes to get to the scene,” Pickard said. “We could be there in 12 seconds.” The county even turned down Convalescent Transport’s offer to respond to emergency calls for free. Now Pickard worries that Hurricane Isabel could further expose Lenoir County’s faltering EMS system. Even though call volumes can triple after a hurricane, Convalescent Transport says the county still has not asked the company for help.

Convalescent Transport provides non-emergency medical transportation, and, until recently, it could respond to emergencies if callers dialed the company directly. That arrangement was complicated when a new state law required all emergency calls to go through 911. Pickard thinks the county could still comply with the law by connecting 911 callers who ask for the company to a Convalescent Transport operator or by dispatching Convalescent Transport ambulances itself. The state Office of Emergency Medical Services recently confirmed that the county could allow Convalescent Transport to respond to emergency calls.

However, the county has refused Pickard’s suggestions, and in so doing has effectively outlawed private emergency transport. “Our motto used to be ‘Providing all your medical transport needs,’ but we’ll have to change that now,” laments Pickard.

Lonely and painful

Craig Sullivan thinks Lenoir County’s aversion to private EMS is to be expected in North Carolina. Sullivan directs Watauga Medics Inc, and said that being a private EMS provider in North Carolina is “very, very lonely and painful.” The Journal of Emergency Medical Services reports that private transporters serve 42 percent of America’s 200 largest cities. However, in North Carolina, Sullivan’s company is one of only two private primary providers.

Convalescent Transport has operated in the area for 13 years, but the company now struggles without its emergency transport revenue. Falling income has forced the company to turn to layoffs. Moreover, like it or not, the county’s 60,000 residents now have no alternative to county service. Says Pickard, “If I were a patient I would feel like my freedom of choice has been taken away.”

Pickard doesn’t think it has to be this way. He sees a clear opportunity for a symbiotic relationship: Convalescent Transport could use the revenue generated by emergency transport, and the county could use the extra help.

Last year the county’s emergency medical services responded to more than 6,000 calls, and Pickard believes that Convalescent Transport could lighten that load significantly. The company had banked on third-party reimbursements to make up for the offer to forego county money. Pickard thinks Convalescent Transport could improve the county’s 10-minute 31-second average response time. “In the city areas we could drop that response time to six or seven minutes easily,” Pickard said. “Who would turn down free help?”

“Nothing is done free of charge,” said County Manager John Bauer. Bauer is skeptical of Convalescent Transport’s offer of free help, but even if it were free, he worries that allowing 911 operators to dispatch Convalescent Transport ambulances would lead to logistical problems.

“We’d have others who would want in, too,” Bauer said. “Then you have multiple providers, and you get into problems where someone says you’re favoring one over another.” Bauer said logistical problems could bring liability problems if emergency transport providers get into accidents: “We don’t need to get our citizens hurt in a race.”

However, just as the county has prevented Convalescent Transport from responding to emergency calls, it would also have the authority to prevent other would-be providers from entering the market. In fact, Convalescent Transport would like to enter the market more completely and respond to all emergency calls. Pickard estimates his company could serve the county for at least $600,000 less than the $2.6 million yearly cost of in-house provision. He also thinks Convalescent Transport has other factors on its side.

The company has operated in the area for 13 years, compared to two years for the county provider. And the private company has 12 ambulances to the county’s five. Indeed, the quality of Convalescent Transport’s service never seemed to be an issue, not even with Bauer: “I’m only going to say good things about Convalescent Transport. They’re a professional organization and we’re a professional organization.”

However, given the current political climate, Pickard sees little chance of expanded private provision. When asked why private EMS has stalled in North Carolina, Sullivan cites an unfriendly political climate exacerbated by meager Medicare reimbursements:

“One of the reasons private EMS didn’t catch on here is that Medicare reimbursements didn’t catch up. North Carolina and Tennessee have the lowest reimbursements for Medicare so county governments just think ‘we’re going to have to subsidize everything so just do it ourselves.’”

Still, Sullivan estimates that Medics Inc. saves the county $300,000 per year, and he contends that privatization could succeed elsewhere in North Carolina. Sullivan thinks perception — perhaps as much as politics — stands in the way of privatization’s progress: “A lot of county officials don’t even know it’s an option. I talked to a guy from another county and he said, ‘Wow, you’re private — I didn’t know that was possible.’”

Big emergencies

Pickard thinks the county simply wants the revenue generated by emergency transport. He cites an incident report from August in which a Convalescent Transport ambulance encountered a three-automobile accident while returning from another call. Although Convalescent Transport can no longer respond to emergency calls, Pickard said EMS personnel have a duty to act in such situations.

The Convalescent Transport crewmembers tended to the three injured people and loaded them into their ambulance, but before the crew could transport the patients to the hospital the county’s EMS training officer arrived and said that only a county ambulance could transport the patients. The county ambulance arrived 20 minutes later.

“What if you were one of those patients?” Pickard asked. “An ambulance shows up with certified crewmembers and starts checking you out. You’re sitting in the back of a perfectly good ambulance, but you have to wait 20 minutes for another one? It’s totally absurd!”

Luckily, the accident victims did not suffer serious injury, and Bauer said the county would call on the private company in extreme situations: “If there’s a big emergency and all five ambulances are in use we will call Convalescent Transport.”

There was a big emergency in January. The West Pharmaceutical plant exploded, leaving six dead. Bill Howard estimates that Convalescent Transport provided the most emergency support that day, and he doesn’t understand why the county would not turn to the private company for the burgeoning emergency of slow response times in rural areas. Howard has 20 years experience in firefighting, and he sits on the board of the fire department that serves Hugo, a rural community within Lenoir County. He blames the county commissioners for the slow response time his community must endure.

“They’re going to run you off a pretty little chart that says they have a response time of 9, 10 and a half minutes, but most of those are in the city,” Howard said. “If you get out here in the rural areas there’s no way they’re averaging 10 and a half minutes.”

What may seem particularly troubling is that a 10 1/2-minute response time is not exactly stellar. The Mayo Clinic recently placed the critical marker at six minutes — responding to a cardiac arrest patient within six minutes greatly increases survival rates, but after six minutes the chance of survival plummets. Howard said emergency patients in Hugo have had to wait as long as 26 minutes for an ambulance. Howard’s frustration mounts when he explains that a recently enacted property tax increase was supposed to have improved response times in rural areas. Only he hasn’t seen any improvement.

“We’ve got the same thing we had prior to the tax increase,” Howard said. “No improvement. No new equipment. We haven’t received anything except a tax.” Howard thinks the county should contract with Convalescent Transport to help improve rural response times. And, even before the stroke victim died, Howard worried that tragedy would come sooner than EMS reform: “My hope is that before someone has to die someone in politics will wake up and realize that this is happening.”

Ted Balaker is the Jacobs Fellow at the Reason Public Policy Institute, and editor of the newsletter Privatization Watch.