Genesee County Ambulance Transport Option Analysis Report

Transcription

1 Consultant Report Genesee County Ambulance Transport Option Analysis Report April 5, Marshall Road, Box 170 Platte City, MO (816)

2 Consultant Report Genesee County Ambulance Transport Option Analysis Report Table of Contents INTRODUCTION 1 MODELING ASSUMPTIONS 2 Rapid Paramedic Response/Safety Net 2 Response Time Standards 2 New System Framework 3 METHODOLOGY & FINDINGS 5 Cost to Provide Service 5 System Revenues 6 Sustainability 6 Options Modeling Outcome Summary 6 ECONOMIC ISSUES 8 EMS Funding 8 Procurement Safeguards 8 LEGAL ISSUES 10 Authority Over EMS/Ambulance Services 10 STAKEHOLDER ISSUES 11 Protecting Current EMS Workers 11 Current Ambulance Organizations 11 DECISIONS & NEXT STEPS 12 Policy Decisions 12 Decision Calendar 12 Appendix A: Ambulance Transport Option Modeling Report Appendix B: Legal Opinion: Authority to Operate and Regulate EMS System FIGURE 1. RECOMMENDED FRAMEWORK FOR GENESEE COUNTY EMS SYSTEM 4 FIGURE 2. FINANCIAL COMPONENTS FOR THREE OPTIONS FOR GENESEE COUNTY EMS SYSTEM 7 FIGURE 3. SEQUENCE AND CALENDAR FOR KEY DECISIONS AND ACTIONS 13 Fitch & Associates, LLC Page i Genesee County April 5, 2006 Option Analysis Report

3 Introduction In August 2005, Genesee County engaged Fitch & Associates, LLC to review the County s Emergency Medical Services (EMS) system including a review of the use of EMS millage funds. The consultant report was delivered in September 2005 and included immediate action items along with recommendations for future system changes. The high level findings of the report are: The system does not benchmark well against more patient focused systems. Cohesive governance and independent oversight are lacking. The EMS millage was originally designed to support a paramedic program. In addition, the City of Flint has used the funds to support its fire first responders, which was not the original intent of the millage. Elected officials must act in a timely fashion to ensure the public health and safety. The report proposed three options for the future Genesee County EMS system: a Status Quo approach; a higher level of coordination and regulation utilizing one or multiple providers/zones and integrating both emergency and non-emergency services; and a third option that utilized a single ambulance provider and potentially reduce the role of the paramedic first response program. Statements made by the County Commissioners indicated that neither option one or three were desirable and, as noted later in the report, the Sheriff s paramedic program plays a unique and integral role in the present and future system. The Consultants therefore explored the viability of an improved emergency-only model and both single and multiple provider models that provided an improved integrated emergency and non-emergency ambulance system. This phase of the project included identification of key public policy issues and the development of sustainable operational and financial models for the delivery of emergency medical transport services countywide. The detailed analysis of data and the modeling results are included for review in Appendix A of this report. Fitch & Associates, LLC Page 1 of 13 Genesee County April 5, 2006 Option Analysis Report

4 Modeling Assumptions Rapid Paramedic Response/Safety Net The County s Sheriff s Office Paramedic Program is a key component of the Genesee County EMS system. One of the unique characteristics of this program is that the Sheriff s paramedics can rapidly enter a potentially violent scene to give aid. And, as an added bonus to the community, these units provide an increased law enforcement presence when not on EMS assignments. The response time standards used in the options modeling are dependent on this rapid advanced life support (ALS) response to medical emergencies. Continuation of Sheriff s Paramedic Program is a basic assumption for all options considered. The City of Flint Fire Department currently operates one paramedic response unit. EMS millage funds were given to the City under agreement to provide a paramedic program. At least one half of the EMS millage funds, instead support medical first responder services from Flint Fire. The remaining half of the City s EMS millage supports the Flint paramedic ECHO unit. Each year the ECHO unit has responded to fewer and fewer 911 calls and relies more and more on the Sheriff s Office paramedics and private ambulance companies to serve patients within the Flint City limits. Other units of local government have expressed interest in receiving funds for the provision of similar services. The County Commission needs to make a policy decision as to the best use of countywide funding for paramedic first response. Response Time Standards Two response time standards were utilized in the system options models: 8 minutes 59 seconds (expressed as 8:59) for more urban areas and 11 minutes 59 seconds (11:59) for more suburban areas. Both response time standards are measured from receipt of the patient s call at 911 until the wheels stop at the requested address. For purposes of analysis, the first 59 seconds was allotted to medical dispatch and the remaining 8 minutes zero seconds and 11 minutes zero seconds, respectively, were allotted for the actual response and arrival of the ambulance to the patient s side. Fitch & Associates, LLC Page 2 of 13 Genesee County April 5, 2006 Option Analysis Report

5 Initial modeling utilized an 8:59 minute response time benchmark throughout the county and without consideration of geographic call volume density. The operational and financial resources needed to provide this level of coverage and meet the response time requirement for transport units, particularly in the outlying areas was significant. 1 It is common practice for communities with large geographic areas and diverse call volume and population densities to set different response time requirements for transport units in outlying or suburban areas than in urban areas with a denser call volume. 2 A key element in providing adequate medical response to patients in the outlying areas is strict performance standards for the Sheriff s Office paramedics in the new system design. These quick response units should focus on delivering an eight minute response time (8:59 with 90 percent reliability) to the outlying areas to allow for the longer ambulance transport times planned in the system design. New System Framework Regardless of the model selected, the Commission must consider the larger organizational framework for a future EMS system. The current system does not organize the various components in a manner so that they can work together to serve patients with a common vision and mission. The current system is neither accountable nor transparent. In the framework proposed, patient care becomes the primary focus for all system participants. Financial incentives and disincentives for providers are aligned in a business model that reinforces the provision of excellent care, employee development, and system accountability. Medical Control, the three 911 centers, medical and paramedic first responders, ambulance providers and the hospital community along with the State EMS Office are all component entities of the system. Figure 1 is a graphic representation of how the system can be effectively organized. The Medical Control Authority provides 1 Because the call volume is low and the geographic coverage needs are high, a countywide response time of 8:59 would be extraordinarily difficult to maintain and would not represent the best value for funds invested. 2 The impact of this public policy decision in Genesee County is further mitigated by the utilization of the Sheriff s Office Paramedics as first responders in low-density areas. Fitch & Associates, LLC Page 3 of 13 Genesee County April 5, 2006 Option Analysis Report

6 system oversight, quality assurance and sees that the system delivers quality care to the patient. The County Health Department partners with Medical Control in this effort and provides independent review of all parties performance to local elected officials. Legislative action by the Commission is necessary to implement the suggested framework. Figure 1. Recommended Framework for Genesee County EMS System Framework for Genesee County EMS System Development CONSULTING S E R V I C E S Governance Standards Accountability State & County Legislative Authority Dispatch & Medical Direction Partial Funding Operational Oversight Medical Control Authority County Health Oversight GC County Ambulance Regulations Performance contract Service Delivery Mechanisms First Response Service Agency (s) Medical Communications Transport Provider Agency (s) Functional Responsibilities Functions Staff Employment -Supervision Response Training Logistics Performance Capabilities Continuing Education Outcomes & Performance Indicators Fitch & Associates, LLC Page 4 of 13 Genesee County April 5, 2006 Option Analysis Report

7 Methodology & Findings Genesee County 911 Consortium and the Flint Fire 911 centers provided data records from their computer aided dispatch systems for analysis as requested by Fitch & Associates. In the current fragmented system, the only consistent data available is that for responses to requests for service received through the emergency (911) system. Inter-facility ambulance transport data is not systematically collected and analyzed in the Genesee County EMS system or the Medical Control Authority. The analysis utilized available emergency system data and conservative assumptions regarding the number of inter-facility transports. Model assumptions used were a two-to-one ratio, that is, for every emergency transport in the Genesee County EMS system, there is one non-emergency transport. This is a conservative assumption and one that is based on experience across a number of communities. The consultants utilized three statistical methods to analyze the data: mathematical modeling, geospatial analysis and computer simulation methods. The analysis process considered the following variables: historical call volume variations by time of day, day of week, and seasonal variations. A model is constructed that provides the baseline coverage and the number of vehicle operating hours (unit hours) needed to answer the calls within a specified response time and to meet the demand fluctuations. Cost to Provide Service The operating costs of the models are based on the unit hours needed to provide service at varying levels of response time standards. A unit hour equates to the organizational costs associated with operating a staffed and equipped transport ambulance for one hour. A benchmarked unit hour cost is applied. 3 3 Projected costs include provider costs associated with operations, dispatch, facilities personnel, management, margin and system oversight costs for the County and Medical Control but exclude the first response paramedic millage which would remain constant across all options. Fitch & Associates, LLC Page 5 of 13 Genesee County April 5, 2006 Option Analysis Report

8 System Revenues The revenues available in a system are derived from the ambulance transports. Gross billings are reduced by collection rates that are appropriate based on experience in similar communities. Different collection percentages are applied for emergency versus non-emergency transports. Sustainability The system design is deemed sustainable if there are sufficient net revenues to provide for current and long-term operating costs. Options Modeling Outcome Summary Three options were analyzed in the modeling process: 1. Emergency only ambulance system, one provider with numerous nonemergency ambulance services remaining outside the purview of the system 2. Integrated emergency and non-emergency ambulance system, one provider. 3. Integrated emergency and non-emergency ambulance system, two providers, two zones. The emergency only system with one emergency provider costs more to operate than there are revenues to support it. Emergency services, particularly those with performance standards, are expensive to operate and difficult to sustain solely from transport revenues. Revenues for emergency transports are typically collected at less than 50 percent of the amount billed. While a one-provider system eliminates duplication of management and other overhead costs, an emergency only system is operationally demanding (expensive) and cannot be financially sustained. The design does not support one provider; therefore, no further analysis of the option was conducted for additional providers. The integrated emergency and non-emergency transport system with one provider generates enough revenue to sustain operations, contribute to system oversight and medical direction and provide a return on investment. Using this approach, nonemergency, inter-facility ambulances can be operated in a very efficient and revenue productive manner that provides a higher clinical level of care to all patients. In Fitch & Associates, LLC Page 6 of 13 Genesee County April 5, 2006 Option Analysis Report

9 addition to the expanded clinical and operational capability of this approach, the revenues from the non-emergency services offset the additional expense of less predictable, performance stringent and therefore more costly emergency component of the system. These revenues can also be used to the patient s benefit to support other future system enhancements. The ability to sustain an integrated emergency and non-emergency system with one provider suggested that the analysis be continued to model a two provider, integrated emergency and non-emergency system. Two-zone integrated systems require additional operational, clinical and financial oversight. Zones and call loads must be continually re-balanced to ensure both providers have an equal number of transport opportunities. Certain operating expenses are duplicated such as management and facilities costs. However, the number of patients and system revenues are the same as the one provider, emergency and non-emergency option. In the multiple provider approach, operating costs were modeled for two zones and to take into account certain territorial overlaps. Revenues and workload are divided equally between the two providers. The two provider, emergency and non-emergency system did not provide enough revenue to sustain operations. There were no funds available for system oversight, which is more costly with the two zone system. Given the financial non-viability of this option, it was fruitless to analyze the system with more providers. Figure 2 summarizes the financial results of the three options that were modeled in the analysis. Figure 2. Financial Components for Three Options for Genesee County EMS System Option 1: Emergency Only One Provider Option 2: Emergency & Non- Emergency One Provider Option 3: Emergency & Non- Emergency 1st of 2 Providers Option 3: Emergency & Non- Emergency 2nd of 2 Providers No. Transports 41,610 62,415 31,208 31,208 System Revenue $9,846,798 $15,890,651 $7,945,325 $7,945,325 System Costs 4 $12,048,137 $14,949,956 $8,326,888 $8,326,888 Surplus (Loss) $(2,201,339) $940,695 $(381,562) $(381,562) The only feasible option is the emergency and non-emergency, one provider system. 4 Projected costs include provider costs associated with operations, dispatch, facilities personnel, management, margin and system oversight costs for the County and Medical Control but exclude the first response paramedic millage which would remain constant across all options. Fitch & Associates, LLC Page 7 of 13 Genesee County April 5, 2006 Option Analysis Report

10 Economic Issues EMS Funding Funding for an EMS system comes from two primary sources: 1) public subsidy (taxes) and 2) ambulance transport fees paid by insurance companies, Medicare, Medicaid and patients. Genesee County has a long history of funding its Paramedic Program from a special assessment millage. Private and not-for-profit ambulance companies in Genesee County have historically funded their operations from patient transport fees but have not contributed to the funding of system oversight or system improvements. Enhanced funding is needed in the Genesee County EMS system to provide quality assurance, monitor performance system-wide, as well as maintain the community s safety net through the Paramedic Program. Currently, there is minimal medical oversight of care during emergency medical calls and no independent medical oversight for non-emergency or inter-facility transports. These costs were accounted for in developing the future system costs. Procurement Safeguards Whenever public-private partnerships are utilized to provide ambulance services, it is prudent to provide safeguards in the event of non-performance. The current Genesee County ambulance system has no such safeguards and little accountability. There are a number of for-profit and not-for-profit companies currently providing service. They enter and exit the market, for the most part, at will. When the consultants began this study in August 2005, there were 12 ambulance providers. At last count there were eight providers. There are no contracts between the County and the providers. These entities have no financial obligations to continue service. A number of safeguards are in place in other communities that have chosen to contract with one or a few EMS providers. Financial and other operational safeguards include: Guaranteed performance with financial penalties for specifics instances of non-performance. (e.g. per call penalties) Fitch & Associates, LLC Page 8 of 13 Genesee County April 5, 2006 Option Analysis Report

11 Provider line of credit, bond and/or other security mechanisms for breach of contract, Critical infrastructure maintained in, or immediately available to, the public sector (e.g dispatch, radios, ambulances, etc.), Appropriate liability and worker s compensation insurance requirements, Criteria for vehicle maintenance and replacement, Audited financial statements, Independent oversight and annual reports to elected officials. Other components of a well-crafted procurement process and contract include: Assurance that all calls will be answered regardless of the patient s ability to pay, Criminal background checks of medical and management personnel, Annual and for-cause drug testing of employees rendering medical aid, Protection of the Genesee County EMS system name, Participation in public education efforts and coordinated community outreach, Participation with the County in planning, training and exercises for emergency events such as pandemic disease outbreaks or terrorism related events, Participation in meaningful quality improvement processes, Incentives to retain qualified personnel working in the current system, Collaboration with local hospitals to facilitate clinical research and improved care. Communities of varying sizes operate with one EMS provider. It is recommended that Genesee County provide safeguards and enter into a business relationship with its provider. Accountability and responsibility can be vested in one provider if there are strong safeguards that put performance and the patient in the forefront. Fitch & Associates, LLC Page 9 of 13 Genesee County April 5, 2006 Option Analysis Report

12 Legal Issues Authority Over EMS/Ambulance Services Ultimately, Genesee County must exercise its authority to create, operate and regulate an integrated emergency and non-emergency ambulance system. County Corporation Counsel advises that this authority is solid and resides in state statute, State Attorney Opinions and legal precedent. Appended to this report (Appendix B) is Corporation Counsel s legal opinion. Fitch & Associates, LLC Page 10 of 13 Genesee County April 5, 2006 Option Analysis Report

13 Stakeholder Issues Protecting Current EMS Workers One of the most important assets of any EMS system is the experienced paramedics and EMTs that serve the community. This concern has been raised in considering a system transition in Genesee County. A professional procurement process and specific contract requirements can be used to reasonably assure that incumbent personnel are treated equitably and that employment preference can be given to those currently employed by area ambulance services. Current Ambulance Organizations There are a number of ambulance companies in the community, many of whom have provided service in Genesee County over the years. The ambulance model proposed will re-structure unbridled competition IN the marketplace with competition FOR the marketplace to better serve patients. Existing providers have insight and knowledge of the community s ambulance needs. As part of a professionally designed procurement process the County could at its option choose to recognize that experience by offering preferential points to longtime providers. Fitch & Associates, LLC Page 11 of 13 Genesee County April 5, 2006 Option Analysis Report

14 Decisions & Next Steps Policy Decisions There are several key policy decisions for the Genesee County Commission as they move forward to improve the EMS system: Determine the role of the Sheriff s Office Paramedic Program in the future system, Determine the role of the City of Flint EMS millage subsidy and paramedic program in the future system, Decide if the system is to remain fragmented or to go forward with a formal procurement for an improved integrated emergency and non-emergency ambulance services, Initiate actions to move the process forward. The decision-making process certainly resides with the Commissioners, but other key players in the community include the Medical Control Authority, the system Medical Director and Hospitals, the Genesee County 911 Consortium, current ambulance providers, the City of Flint, and other municipal responders. During the coming month, informal discussions between the County and key stakeholders should take place. Decision Calendar Below is a sequence and suggested calendar for key decision points to move the EMS system forward. Fitch & Associates, LLC Page 12 of 13 Genesee County April 5, 2006 Option Analysis Report

15 Figure 3. Sequence and Calendar for Key Decisions and Actions Date April 5 April 5 April 19 April 26 May 9 May 24 Board Decision or Action Consultant recommendations to Public Works Committee Board Chair establishes a subcommittee to study recommendations Subcommittee recommendations reported to Public Works Committee Public hearing on recommendations at Human Services Committee Decision making on policy direction by Board of Commissioners Decision making on millage language by Board of Commissioners Should the Commission decide to go forward, the business and legal structure along with detailed system performance specifications would be developed in early June for the Commission s approval and the formal procurement would follow. Fitch & Associates, LLC Page 13 of 13 Genesee County April 5, 2006 Option Analysis Report

16 APPENDIX A Ambulance Transport Option Modeling Report

17 APPENDIX A GENESEE COUNTY Ambulance Transport Provider Feasibility Study Table of Contents INTRODUCTION 1 PHASE II STUDY PURPOSE 1 METHODOLOGY 2 CALL VOLUME DISTRIBUTION ANALYSIS 4 MONTHLY DEMAND COMPARISON ANALYSIS 4 Analysis City of Flint Calls 5 Call Analysis - Genesee County 6 Comparison: City of Flint & Genesee County Call Volume Distribution 8 HOURLY DEMAND & COVERAGE ANALYSIS 9 HOURLY DEMAND ANALYSIS 9 Hourly Demand (City of Flint Data) 9 90% Coverage Analysis 10 PLOTTING THE DEMAND FOR AMBULANCE SERVICE 13 Two-Zone Coverage 21 SYSTEM COSTS & REVENUES FOR MODELS 24 MODEL/OPTION 1: EMERGENCY ONLY, ONE PROVIDER 24 Unit Hour Needs & Operating Costs 24 Revenues from Emergency Transports 25 Feasibility 26 OPTION 2: EMERGENCY & NON-EMERGENCY, ONE PROVIDER 26 Unit Hour Needs & Operating Costs 26 Revenues from Emergency & Non-Emergency Transports 28 Feasibility 29 OPTION 3: EMERGENCY & NON-EMERGENCY, TWO ZONES & PROVIDERS 29 Unit Hour Needs & Operating Costs 29 Revenues from Emergency & Non-Emergency Transports 31 Feasibility 31 CONCLUSION 33 Fitch & Associates, LLC Page i Genesee County

18 FIGURE 1. DISTRIBUTION OF CALLS FOR GENESEE COUNTY & CITY OF FLINT 5 FIGURE 2. CITY OF FLINT - DAILY DISTRIBUTION BY MONTH FOR EMS 911 CALLS 5 FIGURE 3. CITY OF FLINT FLUCTUATION OF DAILY DEMAND 6 FIGURE 4. GENESEE COUNTY - DAILY DISTRIBUTION BY MONTH FOR EMS 911 CALLS 7 FIGURE 5. GENESEE COUNTY - DAILY DEMAND ANALYSIS 7 FIGURE 6. CITY OF FLINT & GENESEE COUNTY - COMPARISON OF CALL VOLUME DISTRIBUTION 8 FIGURE 7. HOURLY DEMAND (CITY OF FLINT) 9 FIGURE 8. AVERAGE SYSTEM DEMAND AT 90 PERCENT COVERAGE FACTOR (FLINT DATA) 11 FIGURE 9. AVERAGE SYSTEM DEMAND AS MET BY 90 PERCENT COVERAGE FACTOR (EXTRAPOLATED FOR GENESEE COUNTY) 12 FIGURE 10. GEOSPATIAL CALL DENSITY DISTRIBUTION - GENESEE COUNTY (TOTAL) 13 FIGURE 11. GEOSPATIAL CALL DENSITY DISTRIBUTION CITY OF FLINT 14 FIGURE 12. DISPLAY OF URBAN AND RURAL DENSITY GRIDS GENESEE COUNTY 15 FIGURE 13. PRIMARY COVERAGE URBAN AREA 17 FIGURE 14. BALANCED URBAN/RURAL COVERAGE PLAN 19 FIGURE 15. BALANCED URBAN/RURAL COVERAGE PLAN 20 FIGURE 16. GEO-SPATIAL MODELING 21 FIGURE 17. NORTH ZONE BALANCED URBAN/RURAL PLAN 22 FIGURE 18. SOUTH ZONE BALANCED URBAN/RURAL COVERAGE PLAN 23 FIGURE 19. AMBULANCES NEEDED FOR TERRITORIAL COVERAGE & CALL DEMAND AT 80 PERCENT FOR OPTION 1: EMERGENCY ONLY, ONE PROVIDER 24 FIGURE 20. AMBULANCES NEEDED TERRITORIAL COVERAGE AND CALL DEMAND AT 80 PERCENT FOR OPTION 2: EMERGENCY & NON-EMERGENCY, ONE PROVIDER 27 FIGURE 21. AMBULANCES NEEDED TERRITORIAL COVERAGE AND CALL DEMAND AT 80 PERCENT FOR OPTION 3: EMERGENCY & NON-EMERGENCY, TWO ZONES, TWO PROVIDERS 30 TABLE 1. GENESEE COUNTY TIER 1 & TIER 2 CALLS FOR SERVICE 4 TABLE 2. POSTPLAN90 LEVEL TABLE 3. BALANCED URBAN/RURAL COVERAGE PLAN 18 TABLE 4. ZONE 1 (NORTH ZONE) BALANCED URBAN/RURAL COVERAGE PLAN 22 TABLE 5. SOUTH ZONE BALANCED URBAN/RURAL COVERAGE PLAN 23 TABLE 6. AMBULANCE UNIT HOURS NEEDED & PROVIDER COSTS FOR EMERGENCY ONLY SYSTEM 25 TABLE 7. SYSTEM REVENUE FOR OPTION 1: EMERGENCY ONLY, ONE PROVIDER 25 TABLE 8. REVENUES, COSTS & NET REVENUE FOR OPTION 1: EMERGENCY ONLY, ONE PROVIDER 26 TABLE 9. UNIT HOURS NEEDED & PROVIDER COSTS FOR OPTION 2: EMERGENCY & NON-EMERGENCY, ONE PROVIDER 27 TABLE 10. SYSTEM REVENUE FOR OPTION 2: EMERGENCY & NON-EMERGENCY, ONE PROVIDER 28 TABLE 11. REVENUES, COSTS & NET REVENUE OPTION 2: EMERGENCY & NON-EMERGENCY, ONE PROVIDER 29 TABLE 12. SYSTEM COST FOR OPTION 3: EMERGENCY & NON-EMERGENCY, TWO ZONES, TWO PROVIDERS 30 TABLE 13. SYSTEM REVENUE FOR OPTION 3: EMERGENCY & NON-EMERGENCY, TWO ZONES, TWO PROVIDERS 31 TABLE 14. REVENUES, COSTS & NET REVENUE OPTION 3: EMERGENCY & NON-EMERGENCY, TWO PROVIDERS, TWO ZONES 32 TABLE 15. FINANCIAL COMPONENTS FOR THREE OPTIONS FOR GENESEE COUNTY EMS SYSTEM 33 Fitch & Associates, LLC Page ii Genesee County

19 Introduction There are three recognized statistical methods used to interpret EMS response and call data, namely, mathematical modeling, geospatial analysis and computer simulation. Each method has different strengths and weaknesses. Mathematical modeling is the most precise, but is limited to the data that is available. The geospatial analysis is the best method to produce graphical displays of density, but does not produce a high level of detail. Computer simulation is a combination of the two other methods with the added value that it requires less data since the parameters of reality are simulated (for example, travel speed of ambulances in response mode and the time on task for a transport). The final model solution is more attainable if the parameters are realistic. Phase II Study Purpose In Phase II of the Genesee County EMS study, Fitch and Associates was to analyze the available EMS call data and develop sustainable operational and financial models for the delivery of emergency medical services countywide. There were a number of data-driven and operational challenges in this phase, but by utilizing available data and conservative and realistic assumptions, credible models could be developed for the Genesee County EMS system. Fitch & Associates, LLC Page 1 of 33 Genesee County

20 Methodology The first step in determining operational and financial sustainability is to determine the operational effort and the resultant cost of providing the service. Variations of two models are analyzed for sustainability: Multiple and single providers of emergency only ambulance response (non-integrated design), Multiple and single providers of emergency and non-emergency ambulance response (integrated design). In both models, the Genesee County Sheriff s Office Paramedic Program remains in place as the safety net for the public s health and welfare. The most demanding and therefore expensive component of EMS is that of response to emergency 911 calls. Response vehicles can be posted or roam in areas of the most likely calls. Current technology can actually predict calls based on historical data. However, even with prediction technology, the unit operates in the mode of waiting for the next call. Twenty-four hour a-day coverage must be maintained at a level sufficient to respond to the highest number of calls predicted for a certain time whether or not those calls materialize. In contrast, non-emergency, inter-facility calls can be serviced by ambulances that have predictable schedules. Ambulances providing non-emergency transports are more revenue productive per hour since the transports tend to take place during typical workday hours and occur primarily between fixed and predictable locations. A provider can minimize down time between calls and can schedule fewer units in service during typically slow request times such as midnight to early morning. To construct the Genesee County EMS models, data was available from the two primary 911 computer-aided dispatch system that receive and dispatch all but a small number of the emergency medical calls. The Genesee County 911 system does not receive or dispatch requests for inter-facility or non-emergency transports. Two different techniques are used to establish the cost of operations. The first is to determine distribution of calls over different intervals of time (monthly, weekly, daily, hourly). Second, using computer modeling, a level of coverage is established. The sum of the units needed for the Fitch & Associates, LLC Page 2 of 33 Genesee County

21 level of coverage and the number of units needed to cover the call distribution determines the total number of unit hours (staffed ambulance hours) needed. The unit hour demand is a key cost indicator for the system. The operational cost to meet a specific response time standard is determined by multiplying the unit hours needed by the cost per unit hour. Revenues to sustain the Genesee County system will be derived solely from billing and collecting for patient transports from insurance companies, Medicare and Medicaid and patients. Revenue must be sufficient to sustain operations on a longterm basis. For the private sector, there must also be a reasonable financial return to offset initial capital investment and provider a balance between the financial and operational risks and rewards of operating the system. There is no hard and fast rule of what risk/benefit level will attract qualified companies to enter a given EMS system. However, the models attempt to establish a return on investment and an operational system that will attract qualified bidders to the system. Fitch & Associates, LLC Page 3 of 33 Genesee County

22 Call Volume Distribution Analysis The annualized call volume as described in the September 2005 consultant report was used in the analysis. Table 1 below indicates the call volume data. Table 1. Genesee County Tier 1 & Tier 2 Calls for Service CY2003 CY2004 CY2005 Jan. to June No. Responses 37,809 43,360 21,807 No. Transports 31,972 41,510 16,761 No. Emergency ALS 15,829 22,818 7,790 Transports No. Emergency BLS 16,143 18,692 8,971 Transports Source: Medical Control Authority (A call is counted once even though there may be multiple responders to the call). Monthly Demand Comparison Analysis Data must be refined in order to establish the number of unit hours needed. The first is to establish the seasonal distribution of demand. This allows a determination if substantial differences are required due to seasonal changes. If this is the case, the cost of doing business is increased because often the capacity to fill seasonal surges is not present and overtime costs may be incurred. Data is further refined based on 1) the City of Flint responses, and 2) responses in the remaining area of Genesee County. Based on data collected for the September 2005 consultant study, the distribution of calls in the City of Flint versus the County is approximately 42 percent and 58 percent, respectively. Figure 1 below depicts the distribution of call volume between the City of Flint and Genesee County. Fitch & Associates, LLC Page 4 of 33 Genesee County

23 Figure 1. Distribution of Calls for Genesee County & City of Flint Distribution of calls 42.39% 57.61% April Genesee April Flint Analysis City of Flint Calls Data from the City of Flint was analyzed to understand the distribution of demand. Figure 2 below represents the distribution of calls by day of week for the City of Flint for three different months. Figure 2. City of Flint - Daily Distribution by Month for EMS 911 Calls Flint Calls Per Day Distribution Calls Sunday Monday Tuesday Wedensday Thursday Friday Saturday Days of the Week August April Flint December Fitch & Associates, LLC Page 5 of 33 Genesee County

24 It is clear that there is a significant shift in the distribution of demand by day of week. April and December are similar while the demand in August is completely different. This means that staffing patterns will need to be adjusted and a more conservative approach will need to be considered when costing the system. Figure 3 below plots the average, median, minimum and maximum of the monthly demand data for the City of Flint. Figure 3. City of Flint Fluctuation of Daily Demand Fluctuation of Demand (min /max per day) Calls for Service Sunday Monday Tuesday Wedensday Thursday Friday Saturday Days of the Week Average Flint median min max There is a fluctuation of 399 calls per week. The difference between the minimum and maximum is the risk/benefit margin that is considered. Call Analysis - Genesee County Comparative data from the month of April was available for analysis. Data from other months was for total volume, monthly and weekly distribution. Figure 4 displays the call variations by day of week for Genesee County. Similar to the City of Flint data, the different months have significant demand fluctuations. Fitch & Associates, LLC Page 6 of 33 Genesee County

25 Figure 4. Genesee County - Daily Distribution By Month for EMS 911 Calls Genesee County Daily Volume of Activity Ambulance Calls Sunday Monday Tuesday Wedensday Thursday Friday Saturday Days of the Week April July November In the Genesee County analysis, each month appears to have significant variations. Figure 5 below shows the minimums and maximums of daily fluctuations. Figure 5. Genesee County - Daily Demand Analysis Genesee County Fluctuations (Min/Max) Ambulance Calls Sunday Monday Tuesday Wedensday Thursday Friday Saturday Days of the Week Average Median Min Max Fitch & Associates, LLC Page 7 of 33 Genesee County

26 There is a fluctuation of 624 calls per week between the minimum and maximum demand. Comparison: City of Flint & Genesee County Call Volume Distribution It is important to validate whether the distribution of call volume over days of the week for the City of Flint and Genesee County are similar or dissimilar. Figure 6 is a graphic representation of the comparison. Figure 6. City of Flint & Genesee County - Comparison of Call Volume Distribution Distribution Comparison Between Genesee and Flint Calls Sunday Monday Tuesday Wedensday Thursday Friday Saturday Days of the Week April Genesee April Flint Figure 6 demonstrates that the pattern for the volume of calls over a week is similar. The fact that the patterns of calls are similar means that conclusions drawn from the Flint data set are applicable to all of Genesee County. Fitch & Associates, LLC Page 8 of 33 Genesee County

27 Hourly Demand & Coverage Analysis Hourly Demand Analysis The next level of analysis is the hourly distribution of demand. Seasonal variations are also addressed at this point. This level of analysis is used to establish a twenty-four hour costing model. Once this is accomplished, the cost is annualized and a basic costing model is created. For this part of the analysis, City of Flint data was used because it had all the necessary subsets and attributes. Using that data, the potential total volume of calls can be correlated by associating relative demand from the rest of Genesee County. Hourly Demand (City of Flint Data) As part of the analysis of the City of Flint s hourly demand data, the fluctuations of the days of the week were collapsed into a 24-hour period. Figure 7 is a graphic representation of this analysis. Figure 7. Hourly Demand (City of Flint) April-August-December Average Calls Per Hours :00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM Hours of the Day December Average August Average April Average April-December Average Fitch & Associates, LLC Page 9 of 33 Genesee County

28 Collapsing all the months of data into one twenty-four hour period allows the establishment of a reliable average consumption of service. Using the average consumption and the standard deviation of the demand, the level of coverage percent can be established and tested. As Figure 7 above shows, there is significant fluctuation in demand. Demand ranges from approximately one call an hour at 6 a.m. and 3.7 calls an hour at 7 p.m. The percentage of demand coverage is a variable parameter. The higher the demand coverage percentage, the more the system costs to operate. A lower demand coverage percentage will result in lower system costs, but will also result in a higher risk of the system becoming overwhelmed. Risk in EMS is the break point of a system that point at which demand outpaces the supply of ambulances so that performance (response time) suffers. At 100 percent coverage, the system would use the highest call volume day of the year and operate at all times with the number of vehicles needed to match that demand. However, for the remaining 364 days of the year, the demand is less and there would be more vehicles (and costs) than needed in the system. Varying levels of coverage can be analyzed, typically beginning with 90 percent coverage. A 90 percent coverage factor means that 90 percent of the demand can be met on any given day at any given hour with normal staffing and without mutual aid resources. 90% Coverage Analysis Figure 8 below displays the average call demand by hour of day and the capability of the system to meet that demand based on a 90 percent coverage factor. This is the coverage of risk. In other words, Figure 8 displays demand at 90 percent risk coverage, which is not to be confused with coverage of volume. Fitch & Associates, LLC Page 10 of 33 Genesee County

29 Figure 8. Average System Demand At 90 Percent Coverage Factor (Flint Data) Hourly 90% Coverage of Demand Call Volume :00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM Hour of Day Average weekaday demand Normal distribution 90% Figure 8 indicates that 90 percent coverage clearly meets the average demand of the system. Using the City of Flint call distribution data over twenty-four hours as the basis, the total call demand for the County is established. This is an extrapolated value because some difference may exist on the actual call demand per hour in the rest of the County. Since the daily distribution is similar, it is valid to assume that the hourly demand is similar. Figure 9 below used the extrapolated total County call distribution and depicts the average system demand by hour and the capability of the system to meet the demand, again with a 90 percent coverage factor. Fitch & Associates, LLC Page 11 of 33 Genesee County

30 Figure 9. Average System Demand As Met By 90 Percent Coverage Factor (Extrapolated for Genesee County) Total Volume for Genesee County Calls :00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM Hours of the Day Total Volume Average Total volume 90% The extrapolated data indicates that the call variation for the entire County is approximately two calls an hour at 6 a.m. and six calls an hour at 7 p.m. 1 This translates to the need for one unit hour (staffed ambulance hour) based on the assumption of one hour time on task per transport. Coverage is the most commonly missed element of ambulance costing calculations. Coverage is the cost of establishing a performance level. To attain a desired response time, the appropriate numbers of vehicles are required at the appropriate place. The preferred methodology to establish coverage is historical data and observations of response times at given intervals of available vehicles. This type of analysis was not possible with the data available and instead, a mix of computer simulation and geospatial plotting of demand was conducted for credible results. 1 The analysis assumes that an ambulance, on average, is out of service one hour to answer a call, transport and deliver a patient to a hospital and return to service. Fitch & Associates, LLC Page 12 of 33 Genesee County

31 Plotting the Demand for Ambulance Service The City of Flint and the Genesee County 911 Consortium supplied six data files for analysis. Historical response data was validated programmatically with varying degrees of certainty. This is done by using a commercial database against which the 911 data street and address is matched. Within the City of Flint the data validated at a rate of approximately 93% and the remaining Genesee County data validated at a rate of approximately 76%. This was the result of free form formatting of address and intersection information, as well as differences in spelling between the source data and the geographic database used in validation. The validation rates are within acceptable ranges and will not materially or negatively affect geospatial analysis and plotting. Based on the six data files, the geospatial analysis provides a visual display of call locations. Figures 10 and 11 are the geospatial display of call distribution based on Genesee County and City of Flint data respectively. The geospatial analysis will also used to determine call density and response time intervals. Figure 10. Geospatial Call Density Distribution - Genesee County (Total) Fitch & Associates, LLC Page 13 of 33 Genesee County

32 Figure 11. Geospatial Call Density Distribution City of Flint The east/west line drawn across the map establishes a distribution of demand that considers both equal call volume and equal territory within Genesee County as follows: 2 Number of calls (demand) for each zone: approximately 1,475 calls per month Size of North Zone: square miles Size of South Zone: square miles This geospatial data per zone is discussed later in this Appendix in the feasibility analysis of zones. In order to allow for urban and rural response coverage, density bands were created by grouping data into one-kilometer grids. Each grid is then evaluated to establish that at least two calls occur per month in the grid. If so, that grid is labeled urban, if not, the grid is labeled rural. A methodology is employed to assign and avoid stand-alone grids by checking surrounding square kilometers and assigning a like label. The urban and rural titles indicate density bands and not actual rural and urban zones. Figure 12 below displays the one-kilometer density grids. The one-kilometer density grid approximates.39 square mile. Red color grids quality as urban and the blue color grids quality as rural based on the definitions above. 2 Based on data for the month of April. Fitch & Associates, LLC Page 14 of 33 Genesee County

33 Figure 12. Display of Urban and Rural Density Grids Genesee County For any cell to be classified as urban (red color), the cell must have a call density of at least two calls per month based on historical data and at least half of the eight bordering cells must also have experienced two calls per month. All other grids are labeled rural (blue color). The grids are used to establish optimal response coverage for response times of: Urban Areas at 8 minutes zero seconds (displayed as 8:00) Rural Area at 11 minutes zero seconds (displayed as 11:00) The optimal response time goal is 8 minutes 59 seconds. In this analysis, one minute is reserved for the 911 call intake and dispatch of the vehicles. An urban versus rural designation is made for several reasons. Providers will place ambulances where the most calls occur which tend to be the more densely populated areas. By doing so, providers respond to more calls, more quickly thereby meeting response time requirements and generating revenue more efficiently. If a requirement is made to respond to all calls in all areas at the same response time, regardless of the number of calls in an area or the distance between Fitch & Associates, LLC Page 15 of 33 Genesee County

34 calls and hospital destination, then the system becomes more costly. Ambulances must be placed in outlying, low call volume areas in order to meet responses time standards. In this situation, there is a trade off at the policy level and a longer response time standard is designated for the outlying areas. Care issues can be offset if there are other first responders readily, particularly if they can deliver rapid paramedic response. Continuing the analysis based on the geospatial information and the given the urban and rural grid designations, three distinct deployment plans were modeled: 1. Primary Urban response plan with rural coverage added. 2. Urban and rural balanced coverage plan. 3. Urban and rural balanced response plan but for two distinct zones. Table 2 below is a posting plan analysis that achieves an 8:00 response time with 90 percent demand coverage. A 90 percent urban preference is noticeable by the fact that ambulances are situated in the urban core and none are in the rural areas (see Figure 13). This is for illustration purposes only and would likely not be utilized in a countywide system approach. Table 2. PostPlan90 Level 20 Name PolyNum Latitude Longitude Class Count Total Percent U % U % U % U % U % U % U % U % U % U % U % U % U % U % R % R % R % R % R % R % Note: Class U = Urban Post (8.0 minute response area) Class R = Rural Post (11.0 minute response area) Fitch & Associates, LLC Page 16 of 33 Genesee County

35 This plan provides urban coverage prior to establishing rural coverage. The first column indicates that it takes 14 vehicles on standby prior to attaining 90 percent coverage on demand. Deployment of the 14 vehicles to achieve 90 percent urban coverage is indicated on the map in Figure 13 below. Figure 13. Primary Coverage Urban Area In modeling a balanced urban/rural coverage plan, lower levels of urban deployment are assigned because the additional rural units will offset up to 10 percent of the urban coverage requirements. Therefore, the geo-spatial plan is modeled at 80 percent urban coverage. Table 3 shows a post plan designed to activate the desired response times. Fitch & Associates, LLC Page 17 of 33 Genesee County

36 Table 3. Balanced Urban/Rural Coverage Plan Name PolyNum Latitude Longitude Class Count Total Percent U % U % U % U % U % U % U % U % R % R % R % R % R % R % R % R % R % R % R % R % Note: Class U = Urban Post (8:00 minute response area) Class R = Rural Post (11:00 minute response area) Figure 14 below represents the deployment plan to obtain required response times. Two of the locations are outside the county boundaries. This is shown strictly to indicate the high level of activity that is currently occurring there. For actual coverage those points would need to be brought back into the county. A mutual aid agreement should be developed to deal with cross county calls. Fitch & Associates, LLC Page 18 of 33 Genesee County

37 Figure 14. Balanced Urban/Rural Coverage Plan This model suggests that coverage of demand can be met with an urban and rural response mix. The number of ambulances needed for geographic coverage is added to the base number of ambulances needed to cover the call activity. This will give the total number of ambulances required to deliver the service. Adjustments are made to move the out-of-county position within the Genesee County boundaries. Figure 15 represents the suggested coverage posts. Fitch & Associates, LLC Page 19 of 33 Genesee County

38 Figure 15. Balanced Urban/Rural Coverage Plan Even after the adjustment to move posts within the County boundaries, post number 19 is in a barely usable location. The deployment model was further refined and posts were readjusted. This adjustment will correct the placement of the vehicles, which then forces a final redistribution of post locations. The final post coverage deployment is as follows in Figure 16. Fitch & Associates, LLC Page 20 of 33 Genesee County

39 Figure 16. Geo-Spatial Modeling The above posts represent only the modeled ambulance locations for optimal coverage of Genesee County. These are not fixed locations, but areas that ambulance (and the Sheriff s Office paramedics) can use as a starting point. Over the period of 12 to 24 months, historical data can be used to build new prediction models for deployment. Two-Zone Coverage Two zones were created to ascertain deployment issues for that configuration. The same methodology was used to establish the zones as used above: balanced urban/rural percent coverage with an urban to rural mix for each zone. Figure 17 and Table 4 below show the results first for the north zone and Figure 18 and Table 5 show the results for a south zone. Fitch & Associates, LLC Page 21 of 33 Genesee County

40 Figure 17. North Zone Balanced Urban/Rural Plan The above posts would be the optimal ambulance locations to cover the North Zone. The limited call volume works against the optimization of coverage and is more difficult. It is likely to create a wandering ambulance syndrome in which an ambulance is posted to capture a small cluster of calls. Table 4. Zone 1 (North Zone) Balanced Urban/Rural Coverage Plan Name Number Latitude Longitude Class Count Total Percent U % U % U % U % R % R % R % R % R % R % R % R % Fitch & Associates, LLC Page 22 of 33 Genesee County

41 Figure 18. South Zone Balanced Urban/Rural Coverage Plan The above locations would be optimal for coverage of the south zone. Table 5. South Zone Balanced Urban/Rural Coverage Plan Name Number Latitude Longitude Class Count Total Percent U % U % U % U % U % R % R % R % R % R % R % R % Fitch & Associates, LLC Page 23 of 33 Genesee County

42 System Costs & Revenues for Models This section of the analysis develops the number of ambulance units hours needed, provider operating costs and the system revenues. An emergency only ambulance system is modeled first and then an integrated emergency and non-emergency ambulance system is modeled. If either model is sustainable, it is further analyzed for additional providers using a zone method. Model/Option 1: Emergency Only, One Provider Unit Hour Needs & Operating Costs The number of ambulances needed to provide 80 percent coverage for emergency only, in an urban and rural response time pattern is shown by time of day in Figure 19. Figure 19. Ambulances Needed for Territorial Coverage & Call Demand at 80 Percent for Option 1: Emergency Only, One Provider 60 Minute Time on Task Plus Coverage Vehicles Required :00:00 AM 1:00:00 AM 2:00:00 AM 3:00:00 AM 4:00:00 AM 5:00:00 AM 6:00:00 AM 7:00:00 AM 8:00:00 AM 9:00:00 AM 10:00:00 AM 11:00:00 AM 12:00:00 PM 1:00:00 PM 2:00:00 PM 3:00:00 PM 4:00:00 PM 5:00:00 PM 6:00:00 PM 7:00:00 PM 8:00:00 PM 9:00:00 PM 10:00:00 PM 11:00:00 PM Time of Day normal time Calls plus coverage Fitch & Associates, LLC Page 24 of 33 Genesee County

43 Using the unit hour demand for the emergency calls and transports developed earlier in this Appendix, the daily, weekly and annual ambulance unit hour needs are calculated. The unit hour need and the cost of operations is displayed in Table 6. Table 6. Ambulance Unit Hours Needed & Provider Costs for Emergency Only System Unit Hours Per Unit Hours Needed Cost at $ Per 24 Hours $33,009 Per Week 2, $231,060 Per Year 123, $12,048,137 The estimated annual operating costs the emergency only, one provider option is $ million. Revenues from Emergency Transports Revenues from transports are calculated based on the modeling of 114 transports per day. Emergency transports typically have a low collection rate. The model applies a conservative gross charges to net collection rate of 47 percent of billings for emergency calls. Table 7 below indicates the transports by advanced life support (ALS) and basic life support (BLS) categories, their typical billing rate for this area and a per mile transport charge. Gross revenues are reduced to reflect the expected net revenue collections. Table 7. System Revenue for Option 1: Emergency Only, One Provider Transports Charges Revenue Total Transports 41,610 ALS (55%) 22,886 $525 $12,014,888 BLS (45%) 18,725 $415 $7,770,668 Mileage Average 7 $4 /mile $28 $1,165,080 Gross Billings $20,950,635 Net 47% $9,846,798 3 Unit hour costs include provider costs associated with operations, facilities, personnel, dispatch, management, margin and system oversight costs for county and medical control but exclude the paramedic millage which remains constant across all options. Fitch & Associates, LLC Page 25 of 33 Genesee County

44 The emergency only, one provider ambulance system generates an estimated $9.8 million in annual revenues. Feasibility The system design option must produce enough revenues to cover annual operating costs. Table 8 summarizes the financial components of the emergency only, one provider ambulance model. Table 8. Revenues, Costs & Net Revenue for Option 1: Emergency Only, One Provider Revenue Less Expenses Provider Net Revenue $9,846,798 Provider Cost $12,048,137 Surplus (Loss) $(2,201,339) The emergency only, one provider option is not sustainable. The annual estimated losses are substantial. The system design cannot support one provider and there is no reason to move forward and develop a model with additional providers since revenues would be the same and a multiple provider model would add overhead and other costs to the system. Option 2: Emergency & Non-Emergency, One Provider Unit Hour Needs & Operating Costs The number of unit hours needed to operate an integrated emergency and non-emergency ambulance system is the combination of the unit hours for the emergency transports at the 90 percent coverage level with an 80 percent urban and rural mix in response plans as determined previously, plus the unit hours needed to cover the more predictable non-emergency or interfacility transports. Data on non-emergency transports is not available from the Genesee County EMS system. For purposes of the analysis, a two to one ratio of emergency to non-emergency calls is assumed. For every two emergency transports, there is one inter-facility transport. This is a conservative, but defensible assumption that results in a percentage distribution of 66 percent emergency and 33 percent non-emergency transports. Figure 20 below indicates the unit hours needed for a one provider, emergency and nonemergency integrated system. Fitch & Associates, LLC Page 26 of 33 Genesee County

45 Figure 20. Ambulances Needed Territorial Coverage and Call Demand at 80 Percent for Option 2: Emergency & Non-Emergency, One Provider 60 Minute Time on Task Plus Coverage + Interfacilities Vehicles Required :00:00 AM 1:00:00 AM 2:00:00 AM 3:00:00 AM 4:00:00 AM 5:00:00 AM 6:00:00 AM 7:00:00 AM 8:00:00 AM 9:00:00 AM 10:00:00 AM 11:00:00 AM 12:00:00 PM 1:00:00 PM 2:00:00 PM 3:00:00 PM 4:00:00 PM 5:00:00 PM 6:00:00 PM 7:00:00 PM 8:00:00 PM 9:00:00 PM 10:00:00 PM 11:00:00 PM Time of Day Normal calls plus coverage + Interfacilities Using the unit hour demand developed, the daily, weekly and annual ambulance unit hour needs are calculated. The unit hour need and cost of operations is displayed in Table 9 below. Table 9. Unit Hours Needed & Provider Costs for Option 2: Emergency & Non-Emergency, One Provider Unit Hours Per Unit Hours Needed Cost at $ Per 24 Hours $40,959 Per Week 2, $286,711 Per Year 153, $14,949,956 The estimated annual operating costs for the integrated emergency and non-emergency ambulance system is $14.9 million. 4 Provider unit hour costs include all costs associated with operations, facilities, personnel, dispatch, management, margin, oversight and medical direction. Fitch & Associates, LLC Page 27 of 33 Genesee County

46 Revenues from Emergency & Non-Emergency Transports Revenues from transports are calculated based on the modeling of 114 transports per day with the assumption that the system will have at least one inter-facility transport for every two emergency transports. Emergency transports are assumed to be collected at the rate of 47 percent. A much higher percentage of non-emergency calls are deemed collectible and a 70 percent collection is assumed. The system should accomplish 114 emergency transports a day and an additional 57 inter-facility transports. Table 10 indicates the call category distribution, the various charge rates and the system gross billings and net (collected) revenues. Table 10. System Revenue for Option 2: Emergency & Non-Emergency, One Provider Emergency Transports 41,610 Transports Charges Revenue ALS (55%) 22,886 $525 $12,014,888 BLS (45%) 18,725 $415 $7,770,668 Mileage Gross Emergency Transport Billings Net Revenue 47% Inter-facility Transport Billings Net Revenue 70% Net Revenue Emergency & Inter-facility Average 7 $4 /mile $28 $1,165,080 $20,950,635 $9,846,798 20,805 $415 $8,634,075 $6,043,853 $15,890,651 The estimated annual operating net revenues for the integrated emergency and non-emergency ambulance system with one provider are $15.9 million. Fitch & Associates, LLC Page 28 of 33 Genesee County

47 Feasibility The system design option must produce enough revenues to cover annual operating costs. Table 11 below summarizes the financial components of the integrated emergency and non-emergency ambulance system with a one provider model. Table 11. Revenues, Costs & Net Revenue Option 2: Emergency & Non-Emergency, One Provider Revenue Less Expenses Provider Net Revenue $15,890,651 Provider Cost $14,949,956 Surplus (Loss) $940,695 The one provider, integrated emergency and non-emergency system design provides sufficient net revenues to be financially sustainable and provides a surplus. Based on the success of this option, a two provider, integrated emergency and non-emergency ambulance system will be analyzed. Option 3: Emergency & Non-Emergency, Two Zones & Providers Unit Hour Needs & Operating Costs Additional unit hours are needed to operate the two zone, two provider system because of territorial overlap. Because the two providers are assumed to work independently, bordering territorial coverage will be duplicated. In addition, call volume is halved and the coverage of smaller clusters of calls requires more unit hours. Figure 21 displays the vehicle requirements for coverage of two zones Fitch & Associates, LLC Page 29 of 33 Genesee County

48 Figure 21. Ambulances Needed Territorial Coverage and Call Demand at 80 Percent for Option 3: Emergency & Non-Emergency, Two Zones, Two Providers 2 Zones + 60 Minute Time on Task+ Interfacilities Vehicles Required :00:00 AM 1:00:00 AM 2:00:00 AM 3:00:00 AM 4:00:00 AM 5:00:00 AM 6:00:00 AM 7:00:00 AM 8:00:00 AM 9:00:00 AM 10:00:00 AM 11:00:00 AM 12:00:00 PM 1:00:00 PM 2:00:00 PM 3:00:00 PM 4:00:00 PM 5:00:00 PM 6:00:00 PM 7:00:00 PM 8:00:00 PM 9:00:00 PM 10:00:00 PM 11:00:00 PM Time of Day Coverage for two zones +60 minute time on task + interfacilities Using the unit hour demand developed early and adjusted for the additional territorial needs, the daily, weekly and annual ambulance unit hour needs are calculated. The unit hour need and the cost of operations is displayed in Table 12 below. Table 12. System Cost for Option 3: Emergency & Non-Emergency, Two Zones, Two Providers Unit Hours Per Unit Hours Needed Cost at $ Per 24 Hours $45,627 Per Week 3, $319,387 Per Year 171, $16,653,776 For Each of Two Providers $8,326,888 The estimated annual operating cost for the emergency and non-emergency, one provider option is $16.6 million or $8.3 million for each of the two providers in the model. 5 Provider unit hour costs include all costs associated with operations, facilities, personnel, dispatch, management, margin, oversight and medical direction. Fitch & Associates, LLC Page 30 of 33 Genesee County

49 Revenues from Emergency & Non-Emergency Transports The number of ambulance providers does not change the number of transports in the system. Therefore, the system revenue generated in the one provider emergency and non-emergency system is the same regardless of the number of providers. Revenue calculations are provided in the Option 2 section and are summarized again as Table 13 and divided in half equally for each provider. Table 13. System Revenue for Option 3: Emergency & Non-Emergency, Two Zones, Two Providers Transports Charges Revenue Emergency Transports 41,610 ALS (55%) 22,886 $525 $12,014,888 BLS (45%) 18,725 $415 $7,770,668 Mileage Gross Emergency Transport Billings Net Revenue 47% Inter-facility Transport Billings Net Revenue 70% Net Revenue Emergency & Inter-facility Average 7 $4 /mile $28 $1,165,080 $20,950,635 $9,846,798 20,805 $415 $8,634,075 $6,043,853 $15,890,651 Revenue Per Provider (2) $7,945,325 Feasibility The system design option must produce enough revenues to cover annual operating costs. Table 14 below summarizes the financial components of the integrated emergency and non-emergency ambulance system with a one provider model. Fitch & Associates, LLC Page 31 of 33 Genesee County

50 Table 14. Revenues, Costs & Net Revenue Option 3: Emergency & Non-Emergency, Two Providers, Two Zones Revenue Less Expenses Per Provider Net $7,945,325 Revenue Per Provider Cost $8,326,888 Surplus (Loss) $(381,562) The two provider, two zone, integrated emergency and non-emergency system design fails to provide sufficient revenues to cover operation. Based on the experience with the two zones, two provider model, it is not worthwhile to develop a model with additional zones and/or providers. Fitch & Associates, LLC Page 32 of 33 Genesee County

51 Conclusion Table 15 below summarizes the transport, system revenue and provider costs for the three options that were modeled. Table 15. Financial Components for Three Options for Genesee County EMS System Option 1: Emergency Only One Provider Option 2: Emergency & Non-Emergency One Provider Option 3: Emergency & Non- Emergency 1st of 2 Providers Option 3: Emergency & Non- Emergency 2nd of 2 Providers No. Transports 41,610 62,415 31,208 31,208 System Revenue $9,846,798 $15,890,651 $7,945,325 $7,945,325 Provider Costs $12,048,137 $14,949,956 $8,326,888 8,326, Surplus (Loss) $(2,201,339) $940,695 $(381,562) $(381,562) The emergency only ambulance system results in a significant loss. The economies of scale that are gained by integrating the emergency and non-emergency system are lost when zones area imposed and two providers must share revenues. Option 2, an integrated emergency and nonemergency system offers the best opportunity to obtain qualified bidders who can perform in an accountable manner in the Genesee County EMS system. Fitch & Associates, LLC Page 33 of 33 Genesee County

52 APPENDIX B Legal Opinion: Authority to Operate and Regulate EMS System

53 WARD CHAPMAN CORPORATION COUNSEL GENESEE COUNTY CORPORATION COUNSEL 1101 Beach Street, Room 317 FLINT, MICHIGAN TELEPHONE (810) TELEFAX (810) ASSISTANT CORPORATION COUNSEL JOHN G. MANDELARIS NANCY K DILLINGHAM CELESTE D. BELL April 3, 2006 Hon. Chairperson and Members Genesee County Board of County Commissioners 1101 Beach Street, Room 312 Flint, MI RE: Board of Commissioners Authority to Operate and Regulate EMS System Ladies and Gentlemen: Some members of the Board of Commissioners (the Board ) have asked whether, and to what extent, the County is authorized to operate and regulate emergency medical services throughout Genesee County. The short answer is that the County is statutorily authorized both to both operate and to regulate such services throughout the county. What follows is a discussion of the relevant authorities. All of the statutory provisions cited are within the Public Health Code, Article 17, Part 209 ( the Code ). Code section 20904(4) defines emergency medical services as including...the emergency medical services personnel, ambulances, nontransport prehospital life support vehicles, aircraft transport vehicles, medical first response vehicles, and equipment required for transport or treatment of an individual requiring medical first response life support, basic life support, limited advanced life support, or advanced life support. MCLA (4). Such services thus include ambulance services, nontransport prehospital life support services, and medical first response services. As defined by the Code, the term emergency medical services includes vehicles, personnel, and equipment required to transport to treat any individual requiring life support services, regardless of the transported person s status as an emergency or non-emergency patient. See OAG No. 7072, p. 2 (January 18, 2001). As to ambulance and nontransport prehospital life support services, Code section 20948(1) states: A local governmental unit or combination of local governmental units may operate an ambulance operation or a nontransport prehospital life support operation, or contract with a person to furnish any of those services for the use and benefit of its residents....

54 MCLA (1). 1 Code section 20906(3) defines a local governmental unit as a county, city, village charter township or township. Thus, the County is a local governmental unit falling within the authority of section 20948(1). Ambulance operation is defined at section 20902(5) as a person licensed under this part to provide emergency medical services and patient transport, for profit or otherwise. Nontransport prehospital life support operation is defined as a person licensed under this part to provide, for profit or otherwise, basic life support, limited advanced life support, or advanced life support at the scene of an emergency. MCLA (2). Code section (7) provides: Person means... a governmental entity other than an agency of the United States. Accordingly, a person includes the County. The County also is authorized to operate, or, implicitly, to cause to be operated, a medical first response service. MCLA Such a service, for the most part, provides only basic life support. MCLA (7) & (8); Because a public ambulance service must be for the use and benefit of its residents, any service established would have to be available to all the residents of the County. The physical location of the service, however, is at the discretion of the Board and is not prescribed by law. For example, the fact that the service might be based in closer proximity to some population centers than to others, or that it is more convenient to some citizens, would be no indication that the service was not operating for the use and benefit of the entire county, which is the standard applicable under the statute. See OAG 1978, No. 5254, p. 2-3 (January 17, 1978). Accordingly, taken together, these sections authorize the County, at its discretion, 2 to establish, or contract for, an emergency medical services operation for the use and benefit of all County residents that could provide extensive emergency medical services, including varying levels of life support and the transport of the individuals needing these services. An additional question is by what method the County could establish these services. As stated above in section 20948(1), the County could itself operate an ambulance or nontransport prehospital life support operation, or it could contract with another person to furnish those services. Code section implicitly authorizes the County to either operate or contract for the operation of a medical first response service. Code section 20948(3) provides: A local governmental unit may enact an ordinance regulating ambulance operations, nontransport prehospital life support operations, or medical first response services. The standards and procedures established under the 1 The constitutional validity of MCLA has not been tested. It is reasonable to assume it would survive such a challenge, however, because of its similarity to the language of the Kansas City statute unsuccessfully challenged in Gold Cross Ambulance Co. v. Kansas City, 705 F.2d 1005 (CA 8, 1983), cert den 471 US 1003 (1985). 2 No statutory authority mandates the local governmental entity to undertake the provision of an ambulance service to its residents. OAG 1980, No (May 13, 1980); OAG 1978, No (January 17, 1978). If instituted, however, the service must be available to all the residents of the County. OAG 1978, No. 5254, p. 2 (January 17, 1978).

55 ordinance shall not be in conflict with nor less stringent than those required under this part or the rules promulgated under this part. Thus, the County has been granted the power to regulate by ordinance any emergency medical services operation that could be established within the County. Code section provides that the County may finance an ambulance or nontransport prehospital life support services operation through available funds, funds received from the State, the Federal government or private sources, fees for service, or a special assessment. Such a special assessment would be required to be levied, collected and annually determined in a manner conforming as nearly as possible to the procedure provided in MCLA for police and fire special assessment districts. The Attorney General has opined that such a special assessment would be a tax. OAG 1980, No (May 13, 1980). Under that analysis, there would be no practical reason to employ the special assessment approach rather than a regular millage proposal. Finally, the Board is likely interested in knowing who directly supervises the service if the County chooses to undertake the establishment and regulation of an emergency medical services operation. The state has vested in the local medical control authority ( MCA ) the power to supervise emergency medical services in their designated geographical region. MCLA et seq. For example, the MCA is charged with the responsibility of establishing written protocols for the emergency medical services personnel within its region. MCLA (1). It can also temporarily or permanently suspend paramedic privileges within the region. MCLA ; DenBoer v. Lakola Medical Control Authority, 240 Mich. App. 498, 501 (2000). Nonetheless, the County would be engaged in supervising the emergency medical services of the region in concert with the activities of the MCA by virtue of enacting an ordinance which includes performance standards. We thank the Board for the opportunity to be a part of this undertaking. Very truly yours, Ward Chapman Ward Chapman Corporation Counsel Celeste D. Bell Celeste D. Bell Senior Assistant Corporation Counsel