Most people can agree on one thing about the Pinellas emergency medical services system: It's costly.
Beyond that is a ruckus of disagreement over ways to stem the financial hemorrhage. The sides can't even agree on whether to discuss altering the system or just tweaking part of it.
Pinellas County Administrator Bob LaSala is firmly in the tweaking camp. For him, the issue boils down to the cost of the firefighter/paramedics who are first on the scene. Cut those costs, he has said, and that goes a long way toward bringing the system's finances under control.
But many firefighters and fire officials say — and have for years — that Pinellas' dual EMS system, which has the first-responder firefighter handing over a patient to a later-arriving ambulance paramedic, causes a delay in getting to the hospital.
The solution, they say, is to let firefighters transport the patient. Two firefighter-generated proposals have been put on the table.
LaSala is not convinced.
"This proposal will not work," LaSala said of a plan submitted by Palm Harbor fire Lt. Scott Sanford and Lealman fire Capt. Jim Millican. Not only is it unworkable, he said, "it comes apart in the financials."
LaSala made his remarks Wednesday during a meeting with the St. Petersburg Times editorial board. He was accompanied by City Managers Bill Horne of Clearwater, Frank Edmunds of Seminole and Mike Bonfield of St. Pete Beach.
The three proposals — LaSala's and the firefighters' —have some things in common.
All use some form of priority dispatch, in which the 911 dispatcher screens calls to determine their severity and sends the appropriate equipment. All maintain the current method of funding — a combination of property taxes and ambulance user fees, 63 percent of which is paid by the tax-financed Medicare and Medicaid programs.
But the plans have substantial differences. LaSala wants to:
• Leave the structure of the system intact. Callers with minor problems would get a firefighter or ambulance, not both. Callers with severe emergencies would get both, as they do now.
• Cut the number of firefighter positions being paid by the EMS property tax from 85 to 72. A position is at least the three people needed to staff a vehicle 24/7. The system would lose at least 39 people.
• Pay the countywide average for a firefighter rather than what the employee actually earns. LaSala says this will save county taxpayers about $11 million a year without changing the standard of service, which requires firefighters to respond in 7 ½ minutes 90 percent of the time. And, he said, it gives departments an incentive to keep costs low.
LaSala's plan has been criticized as an attempt to shift a countywide obligation onto fire districts. Others say the plan will slow response times, which now average four to 4½ minutes for medical calls.
Critics also say the plan maintains the handoff from firefighter to ambulance paramedic that delays hospital care. They say it causes redundancies and hands Paramedics Plus a monopoly.
Firefighter transport would avoid that, most in the fire service say. The two plans on the table came from firefighters with years of frontline experience. Both would:
• Eliminate Sunstar from all 911-generated medical calls and let firefighters transport people.
• Rely on rescue vehicles that firefighters would use to take patients to the hospital.
• Send only one vehicle to all but the most serious calls, which would get at least one rescue and one fire vehicle.
The Sanford-Millican plan would have firefighters transport in both emergencies and nonemergencies, such as from a nursing home to a doctor and back.
The architects of the Sanford-Millican plan say it would save $20 million to $22 million over the first three years.
LaSala said the plan doesn't improve response times and still has the handoff delay.
"The turnover time from (a fire) engine to a fire transporter would be the same, and the 'wait time' in completing necessary reports and procedures before leaving for the hospital would be the same," LaSala said.
But Millican said there would be no handoff in most cases. The firefighters who answered the call would transport the patient. Reports could be completed on the way to the hospital.
The other plan, by Seminole District fire Chief Rick Koda, has two firefighters in a rescue responding. But Koda would not have firefighters transport in nonemergencies. Private companies would handle those and compete, which could mean lower costs.
Koda estimates his plan could save $16 million a year and produce a surplus of about $4.8 million that could replenish reserves.
LaSala has criticized both plans as unworkable and said the financial analyses are incorrect.
Horne, the Clearwater manager, saw another problem: the cost of firefighters. With no incentive to keep salaries low, union negotiators and firefighters could talk local officials into higher pay and benefit packages.
Firefighter transport also requires changing the structure of the system. That's not something LaSala and the three city managers are interested in discussing. The system is good, they said.
But others say LaSala simply doesn't want to listen to other solutions despite his assurances that he's open to "good ideas."
"I've never seen the openness to other ideas than what he's bringing forth," Pinellas Park City Manager Mike Gustafson said. Gustafson, whose city has endorsed discussing firefighter transport, served on an EMS resource group LaSala set up.
Palm Harbor fire Chief Jim Angle, who supports the Sanford-Millican plan, agreed that this is a good time to study fire transport.
"I'd like to see an infusion of new ideas," Angle said. "I think we have a great system, a good response time, but there are other ways to do it."
Reach Anne Lindberg at firstname.lastname@example.org or (727) 893-8450.
|Comparing the plans
Pinellas County Administrator Bob LaSala and three firefighters — Rick Koda of the Seminole Fire Department, Scott Sanford of the Palm Harbor Fire Department and Jim Millican of the Lealman Fire Department — have suggested ways to change the county's emergency medical services system. Here is an outline of the plans, comparing them to the existing system.
|How it works||Who comes||Who pays||System cost||Savings||Advantages||Criticisms|
|Existing system*||Generally, when someone calls 911 for medical help, the dispatcher notifies Sunstar and firefighter/paramedics at the nearest fire station. Firefighter/paramedics provide immediate care. When an ambulance arrives, those paramedics may assist. Firefighters transfer the victim to Sunstar, which takes him to the hospital and provides care on the way. Sunstar paramedics also provide nonemergency transport — from a nursing home to doctor, for example. Sunstar paramedics are employees of Paramedics Plus, a private company hired by the county.||The most serious cases get at least four people in two vehicles. Two from fire department and two from ambulance company. Firefighters might be in a fire truck or a rescue — a vehicle that resembles and is outfitted like an ambulance. The least serious cases get an ambulance with two people or a fire vehicle with at least two people, but not both.||Property owners through a countywide property tax; patients who use ambulances. Most costs are paid through Medicare, Medicaid and private insurance.||The budget for the 2010-11 fiscal year was about $106.1 million. Of that, $43.9 million goes to the 18 fire districts that provide EMS. Another $34.9 million goes to Paramedics Plus (Sunstar), the for-profit company that provides ambulance service. About $3.2 million is for supplies, about $3 million for billing and $1.2 million for a medical director. About $19.4 million is in reserves.||N/A||1. Response is rapid. Firefighter/paramedics' average time to arrive on the scene of a medical emergency is 4 1/2 minutes. 2. Treatment is good.||1. The system has built-in delays to hospital care and to getting firefighter/paramedics back on the road. 2. It's expensive. 3. Redundant. 4. Wasteful. 5. Taxpayers have to absorb pay inequities between departments.|
|LaSala plan*||No change||No change||No change||$88 million to $92 million a year. The savings, from property taxes, would come from changing how fire departments are paid. The county would pay for fewer firefighter/paramedics. The departments would be paid the countywide average of pay and benefits.||$11 million to about $15.2 million a year, depending on how many paramedics the county funds.||1. It's fair to equalize the pay and benefits. Cities and fire districts could provide higher pay, more staffers and vehicles if they wanted to pay more. 2. It maintains the standard of having firefighters arrive at the scene within 7 1/2 minutes 90 percent of the time. 3. It saves money by containing costs. 4. It's sustainable.||1. Shifts countywide tax burden to city and fire district taxpayers. 2. Loss of staffers and vehicles means longer response and transfer times. 3. Fire protection will be adversely affected because only fire trucks will be used for medical calls. 4. Does not solve many of the current problems (see above block).|
|Koda approach**||Fire rescue is dispatched when someone calls 911. The closest rescue vehicle responds and takes the patient to the hospital. If it is a critical patient, a fire engine may assist. If the closest rescue is unavailable, the closest paramedic fire engine will be sent. Nonemergency transport would be provided by private ambulance companies that would compete for the business (somewhat like taxicabs).||At least two firefighters in one rescue truck. Additional units may be sent if help is needed. In some cases a paramedic fire engine may respond and keep the rescue unit available for calls with a greater likelihood of taking a patient to the hospital.||No change||About $80.6 million a year.||About $16 million a year. The model claims a surplus of $4.8 million, and it will replenish the EMS reserves.||1. Response of about 4 1/2 minutes. 2. Continuity of care (patient stays with one paramedic crew). 3. Reduced hospital transport times. 4. Eliminates redundancy. 5. Better scene coordination and supervision. 6. Eliminates conflicts between Sunstar and fire crews. 7. Transport profits stay in the system rather than going to a company in Texas. 8. More stable work force.||1. It's not better, cheaper and faster. 2. It's unworkable. 3. Not every fire district wants to transport. 4. Fewer units would be on the street than under the LaSala proposal. 5. Would give no incentive to control the salary and benefit costs of firefighter/paramedics. 6. Not sustainable.|
|Sanford- Millican proposal***||When someone calls 911 for medical help, the operator sends firefighter/paramedics from the nearest station. They provide immediate care, then take the patient to the hospital. Fire departments also would provide nonemergency transport.||At least two in one fire vehicle. Patients with minor symptoms, but likely to be transported, would receive a fire department ambulance. Patients with more severe symptoms would receive an ambulance and a fire truck.||No change||$74.3 million a year, but equipment purchases increase the cost to $79.9 million the first year and $78.2 million the second.||$20 million to $22 million over the first three years after equipment purchases.||1. Maintains response time. 2. Equalizes funding by paying for the type of unit, not employees or the number of patients transported. 3. Saves taxpayer money by containing costs, rather than shifting them from the county to fire departments. 4. A sustainable system. 5. Provides continuity of care and quicker delivery to the hospital. 6. Eliminates duplication in supervisory areas, while adding first responders.||1. It's not better, cheaper and faster. 2. Not every district wants to transport. 3. Analysis is "financially amateurish." 4. Turnover time from fire paramedic to a transporter would be the same (backers say this is not true), and "wait time" procedures before leaving for the hospital would be the same. 5. No incentive to control salary and benefit costs of firefighter/paramedics. 6. Not sustainable.|
|Source: *Pinellas County; **Rick Koda; ***Scott Sanford, Jim Millican|