As the first responders to virtually every serious illness and traumatic injury throughout Riverside County, firefighters and fire paramedics are acutely aware of how every second counts in the race to save lives. Ensuring that those needing emergency care are receiving the quickest and best ambulance care possible is critical to giving the sick and injured the greatest opportunity to make a full recovery.

With the county of Riverside’s contract for ambulance service set to expire soon, I firmly believe that Riverside County has a tremendous opportunity to enhance the pre-hospital emergency medical care it provides to its residents. The best way to accomplish this and to strengthen our emergency response system is by putting the county’s 10-year, nearly $1 billion ambulance contract out for a competitive bid.

Riverside County’s emergency medical system is in need of improvement. For example, our current system allows for a breakdown in the “continuity of care” for the patient. The fire department paramedic who typically responds first does not maintain control over the patient being treated. Under the current contract, that patient must be transferred from the fire paramedic to the ambulance paramedic while on-scene, which ultimately delays the patient’s transfer to the hospital — a critical factor when every second can help save someone’s life.

Another example is that the current ambulance contract includes far too many response time exemptions, allowances and situational excuses that allow an ambulance provider to arrive late with minimal penalty. Under the current ambulance contract, a provider can arrive later than 10 minutes as long as it pays fines. A $5 fine is assessed, if the ambulance is a minute late. This current system is detrimental to residents’ safety, as it provides a disincentive to improve ambulance response times.

Closed-door negotiations are not going to achieve all the improvements that Riverside County residents deserve. Our emergency medical system is 20 years behind those in similarly-situated counties. While all the stakeholders and participants in our current system are to be commended for system upgrades that have occurred over time, there still remains significant room for improvement. Putting the ambulance contract out for a competitive bid through the Request for Proposal (RFP) process allows Riverside County to design exactly what improvements it needs and wants to ensure that our residents are receiving the best possible care.

A competitive bid process for a public contract is always in the best interest of taxpayers, especially when that public contract is valued at as much as $1 billion over a 10-year period. Many of our neighboring counties in Southern California put their ambulance contracts out for competitive bid from qualified providers. Even though the Townsend Paramedic Act of 1980 encourages competitive bidding processes for ambulance service, Riverside County has not put its ambulance contract out for bid for more than 31 years.

Riverside County officials must also ensure that the competitive bid process is structured in a way that does not impact current levels of service. A way to accomplish this is by extending the current ambulance contract by a maximum of one year, which would allow a suitable amount of time to complete the competitive bid process for a new ambulance contract. Jurisdictions such as Los Angeles and Orange counties regularly put out bids for ambulance services and change providers without any disruption to public safety services. There is no reason why Riverside County cannot do the same.

Riverside County puts everything out to bid — from fleet vehicles to road construction to pens and paper. Emergency medical service should be no different. In doing so, I believe that the residents of Riverside County would receive the highest quality of ambulance service possible — certainly higher than our current level of care.

Economics 101 teaches us that by placing this contract out to bid, services would improve and the associated costs would decrease.

Matt Shobert is the fire chief of Murrieta.

dgang@pe.com

Published: 29 February 2012 08:32 PM

A growing number of local officials are urging Riverside County supervisors to competitively bid the county’s contract for ambulance services.

Since last year, county officials have examined the county’s process for dispatching emergency medical calls and are in talks with American Medical Response, or AMR, on a contract renewal for ambulance services.

But city leaders and other officials from throughout the region say the county should put the contract out to bid as a way to improve care, provide better response times and potentially save money.

Murrieta officials have long argued the county should seek bids, and in October the city of Temecula weighed in with support for bidding the contract. Then in December, the Riverside County Fire Chiefs’ Association jumped into the debate, also in favor of opening the bidding process.

Moreno Valley is among the latest to urge the county to seek bids.

“As stewards of the city’s public funds, it is also a priority to ensure that our limited resources are utilized in the most effective manner,” Moreno Valley Mayor Pro Tem Bill Batey wrote to Supervisor Marion Ashley last week.

“As such, it seems only reasonable that a large contract such as that for county emergency medical services be competitively bid.”

AMR, a Colorado-based company, is the exclusive ambulance provider for most cities in western Riverside County, as well as all unincorporated areas.

The company has operated in Riverside County for three decades and had its contract extended in 2004 and 2009. It is up for another three-year extension this year and is negotiating the terms of that deal with the county. The contract has never been competitively bid. The contract’s value is estimated at $95 million.

TRANSPARENCY SOUGHT

In October, the Riverside County Board of Supervisors held a workshop on the emergency medical response system. At the time, several supervisors said competition is healthy and the reasons for a no-bid ambulance contract should be clear cut.

Bruce Barton, director of the county Emergency Medical Services Agency, which oversees ambulance services, was unavailable for comment Wednesday.

Agency spokesman Jose Arballo Jr. said negotiations with the company are ongoing. Arballo said the emergency medical services agency had hoped to come back with a new contract by January. There is no timeframe yet on when the issue will come back before supervisors, he said.

“Last year (in August) the board gave us a specific direction to come back to them with a contract with AMR,” Arballo said by telephone. “There was no mention at that time of setting up a bid process. If the board decides to seek bids, then obviously we will go in that direction.”

Thomas McEntee, AMR’s general manager for Riverside County, did not return a message seeking comment Wednesday.

But in October, he said the company is committed to the county and has worked to improve its operations. For instance, the company is helping fund a digital link between the county and AMR that will allow ambulances to be dispatched more quickly.

In its talks with the county, the company is seeking a five-year wind-down period should supervisors decide to bid the contract. Such a provision would enable the company to recoup its investment, McEntee said at the time.

AMR would compete for the work if the county does seek bids, he said in October.

BIDDING IMPROVES SERVICE

Some officials say the only way to truly improve the county’s emergency medical response system is by opening up the process and seeking competition.

“It is not our contention that the current provider is out of compliance with the contract,” Corona Fire Chief David Waltemeyer, president of the county fire chiefs association, wrote to Barton in December.

“Instead, our assertion is that the contract itself is insufficient and needs substantial modifications that cannot be accomplished with closed-door negotiations leading to a contract extension.”

Among the reasons cited by those who want the county to seek bids are fines AMR has paid for arriving late to calls and the county’s discussions on moving to a dispatch system that prioritizes calls based on medical need.

In recent years, AMR has paid as much as $500,000 a year in late fines. The company has said it is actively working to reduce the amount.

Bidding the contract “in the interests of transparency” also is important, wrote Batey, the Moreno Valley councilman and a professional firefighter.

Supervisor Jeff Stone agreed. In a recent interview, he said he favors opening the process up to competition.

He said he has no bias against AMR, but Riverside County can learn from others who went through similar bid processes and improved services.

“It is healthy for citizens to see that it is a transparent and open process,” Stone said.

But Supervisor Bob Buster said Wednesday he remains undecided on whether to seek bids.

He said AMR is doing a good job and meeting county standards. Buster said the company is making improvements, and he is concerned about how a bid process could affect the changes — such as the prioritized dispatch system — that are under way.

“You want calmer waters, a much more stable situation when you go out and get proposals,” Buster said. “It is a topic where price is important, but also the quality of the service is key. I am still in the process of sorting through everything and looking at the whole situation.”

Riverside has no business enforcing a de facto monopoly on ambulance services. City officials should drop the flimsy rationale for the status quo, and ask the pertinent question they have avoided: Would letting additional ambulance companies operate in the city improve service and cut costs to residents?

Twice in the past five months, the Riverside City Council has rejected applications by ambulance companies seeking a piece of the Riverside nonemergency ambulance business. The city denied applications from Mission Ambulance in October and Alpha Ambulance in December. Only one company, American Medical Response or AMR, provides nonemergency ambulance transport in Riverside. The city controls nonemergency ambulance transport, such as from a hospital to a long-term care facility, through a system of franchise permits which are ostensibly available to any qualified ambulance company. Riverside County oversees emergency ambulance services.

But a state agency last month said Riverside overstepped its authority in rejecting the applications from Mission and Alpha. The city denied the permits on the grounds that there was no public need for additional ambulance service. Yet the director of the state Emergency Medical Services Authority said that Riverside cannot use “need and necessity” to limit ambulance services under state law. That agency has no enforcement authority, however.

But Riverside’s approach was flawed in any case. In practice, the “need” metric consisted of city officials checking AMR’s performance record and deeming it acceptable. The city ducked the question of whether allowing additional ambulance companies into the city would be better for residents. Competition can bolster service and trim costs — no small issue when ambulance transport can easily run $1,000 or more a trip.

Yet the city never bothered to compare Riverside’s costs with prices in areas that have competitive service. Councilman Paul Davis argues that Riverside residents pay far more than in surrounding areas because of AMR’s exclusive contract. Surely that issue should be a central focus of the deliberations.

Even stranger, the city’s approach includes consideration of whether allowing additional companies into Riverside would “impair the economic viability of the existing franchisee.” But that provision creates an insurmountable obstacle for other ambulance companies. Letting another provider operate in Riverside is bound to “impair” the current monopoly holder’s finances.

But why should that be a concern at all? There is no public interest in city government protecting a private business from competitors. That mind-set only invites questions about whether other factors influenced the choice — such as the $1.4 million in paramedic training and equipment that AMR provides Riverside each year under a separate contract.

The city does not benefit from generating public suspicion about undue influence or insider dealing. The council’s only concern should be ensuring good, cost-effective ambulance service. Anything else is irrelevant.

Riverside officials don’t have the right to stop qualified ambulance companies from picking up patients in the city, according to the state agency that oversees county emergency medical service plans.

In Riverside County, all 911 ambulance calls are controlled through a county-approved contract, but county officials say non-emergency transports — such as trips to dialysis — are an open market where multiple providers compete for business.

The city of Riverside requires ambulance companies to have a franchise permit and so far has granted a permit for nonemergency calls only to American Medical Response, which also is the county’s 911 responder.

City officials contend they haven’t limited service to an exclusive provider but say that none of the other applicants met their criteria for service.

The council on Tuesday will consider an application from Los Angeles-based Alpha Ambulance. A committee has recommended denying the permit.

The city’s rejection of all other permit applicants means only AMR’s ambulances can pick up patients in Riverside. But officials with the California Emergency Medical Services Authority, or EMSA, said Riverside “does not have the authority to restrict trade for interfacility transports within their area” because the county’s emergency medical services plan doesn’t give the city that authority, according to a written statement from EMSA.

Riverside City Attorney Greg Priamos said Friday that he disagrees with EMSA’s assessment.

The issue of ambulance service is a complex and contentious one. Emergency medical services has been an organized, regulated system since only about 1980.

Because of the public interest in fast, reliable ambulance response, the state allowed local governments to create monopolies for 911 service and in some cases for nonemergency, or retail, transports. The state requires each county to have a plan for emergency medical services, and EMSA is charged with reviewing and approving those plans.

STATE STANCE

Under state law, the local EMS agency — in this case, Riverside County — is the only entity with the authority to restrict competition in ambulance service, said Daniel Smiley, EMSA’s chief deputy director. If the county’s plan was written to allow cities to regulate ambulance companies, then it would be fine — but Riverside’s plan isn’t written that way, he said.

“We do not believe (the city of Riverside has) the authority to restrict trade in that zone because the (county) plan does not contemplate that at all,” Smiley said.

Going outside the bounds of the county’s EMS plan could make the city vulnerable to antitrust litigation, Smiley said.

Riverside officials have argued they are not creating a monopoly because ambulance franchises are not exclusive; most applicants simply haven’t met the criteria set out in the city’s municipal code. One of those criteria is having a county permit, which means the ambulance company has proper equipment, employee certifications, insurance and the like; the other criteria are showing there’s a need for another provider, and that allowing more ambulance companies won’t economically harm existing providers.

“We do not share EMSA’s view in its entirety, and the city continues to believe that it may regulate nonemergency transports in the absence of any conflicting exercise of state or county authority affecting the same activity,” Priamos said Friday.

He also cited an October 2010 letter from Riverside County Emergency Medical Services Agency Director Bruce Barton. That letter says any ambulance company with a county permit can provide nonemergency transports anywhere in Riverside County, but it goes on to say any provider must operate “in conformance with applicable state, federal and local laws and regulations.”

CITY’S DEFENSE

Priamos said the county has never advised the city that it can’t regulate ambulances through franchise agreements.

Earlier this month, Barton said he wanted to speak with county counsel before responding to EMSA’s comments. He could not be reached Friday.

So far, no one has formally asked EMSA to weigh in on the issue, and Smiley said the agency doesn’t have the responsibility or a mechanism to make Riverside do anything.

If an ambulance provider believes the city is improperly restricting trade, it’s up to the provider to take the issue to court, Smiley said.

There have been numerous court cases among ambulance providers, cities and counties over who controls emergency medical services, he said, but he was not aware of case law on the issue that has been raised in the city of Riverside.