HomeMy WebLinkAbout02/14/2005, SS1 - EMERGENCY MEDICAL SERVICES COST RECOVERY STUDY SESSION council os
j ac En ba Report
CITY OF SAN LUIS O B I S P O
FROM: Wolfgang M.Knabe,Fire Chief
SUBJECT: Emergency Medical Services Cost Recovery Study Session
CAO RECOMMENDATION
1. Receive information on the City's current Emergency Medical Service (EMS) system and
alternatives to the current system.
2. Give staff direction as to which alternatives to pursue, with a focus on the goals of a
dedicated City ambulance and higher emergency medical services cost recovery.
DISCUSSION
There is a long history of issues and options within the region regarding emergency medical
services,including issues pertaining to:
1. Costs
2. Response times
3. Control/Oversight
4. Duplication of service
5. Medicare reimbursements
6. Training
7. Other related issues.
In fact, these issues were so volatile that at one time a Grand Jury investigation resulted Needless
to say, the management of emergency medical services (EMS) is an important and complex issue.
The most recent effort to resolve County-wide EMS concerns resulted in the formation of the
Ambulance Performance Operations Committee (APOC), and an agreement under which EMS
services are provided throughout the County.
The San Luis Obispo City Fire Department responds to approximately 4,300 emergency calls per
year. Of those 4,300 calls, 2,750 (64%) are calls for emergency medical service. This service
includes a 4-5 minute response time by Fire Department paramedics. The citizens of San Luis
Obispo have become accustomed to a very high quality Fire Department emergency medical
service.
Each year Fire Department emergency medical responses increase and the cost of providing these
services have gone up. In fact, San Luis Ambulance Service (SLAS) has increased its rate twice in
the past year and the federal government recently approved a 38.5% reimbursement increase for
California ambulance providers. However this increase was for ambulance providers, not for Fire
Departments, and has not been passed on to the government agencies through the APOC agreement.
However, there is a Medicare provision for a pass-through fee given to fire departments and this
will be discussed in the study session.
1�
Council Agenda Report—EMS Cost Recovery
Page 2
The SLOFD receives a partial reimbursement that covers a small portion of the cost of our
emergency medical services program. The fee is a fixed amount and is only for paramedic
equipment, training, and some incentives. This fee came out of the APOC process and is to
reimburse the Fire Department by the ambulance company for providing first responder services to
the community. The title "first responder fees" is a little misleading because it is not the typical
Medicare eligible pass through fee that other counties have. Our fee is fixed (except for consumer
price index (CPI) increases) and it does not matter if we respond to 2,000 medical calls or 4,000
medical calls.
There are many methods of emergency medical services delivery. There are also many ways that
revenues are generated to pay for these services. Attached to this report are examples from other
cities. The study session will be organized around a Powerpoint presentation that will go into detail
about the history of EMS in the region, issues associated with EMS, other EMS systems in the
State, and alternatives available to Council. Included in the alternatives will be methods of ensuring
that there is a dedicated ambulance for the City of San Luis Obispo.
EMS cost recovery potential depends upon the delivery system, service levels, and related costs.
Before discussing cost recovery we must first look at these issues, and will do so during the study
session.
The alternatives presented in the study session will be as follows:
1. Current system
2. Current system with pass through reimbursements
3. Current system with ALS/BLS fees
4. Current system with secondary SLAS agreement
5. City Fire patient transportation
FISCAL IMPACT
The fiscal impact of an EMS delivery system depends on which system is in place. The study
session will identify the costs and revenue associated with each type of system.
ALTERNATIVES
Continue with current system and direct staff not to pursue other alternatives.. This is not
recommended because it does not provide for a designated City ambulance and does not address the
high cost of EMS to the City.
Attachments
1. Fullerton model/Subscription Program
2. Arcadia model/Subscription Program
3. Ambulance Medicare reimbursement increase
4. Paramedic Tax example
Additional detailed information is available in the Council reading file.
Paramedic Subscription Program-- City of Fullerton, CA Page 1 of 3
ATTACHMENT 1
City of Fullerton __.. ___.._ "sercn�.
Paramedic The_whole city site'�.
f
Subscription
Program
What's New FAQs City Facts Links Help Home
Disclaimer Home: Fire:
312 E. Commonwealth, Fullerton, CA 92832 * Phone (714) 738-6500
Hours: 7:00 to 5:30 Mon-Thu, 7:30 to 5:00 Friday; Closed Alternate Fridays
Fre Home Page L Since July 1983, the City of Fullerton has charged a per call fee for
Int -eri"m Fire Chief]im P PP_ paramedic services. This fee applies to residents and nonresidents
nt
Reed alike, and the amount of the fee depends on the type of service
Fire Stations- - rendered. An ALS (Advance Life Support) charge is currently $300
Questions&Answers and a BLS (Basic Life Support) charge is $200.
about the Fullerton Fire
Department As a Fullerton resident or Business Owner/Manager, you have an
Tips on Dealing with alternative to these per call fees. You can take advantage of a
Household Hazardous special Paramedic Subscription Program that provides paramedic
Waste coverage at a very moderate annual cost. The subscription cost for
Paramedic Subscription one year (July 1 through June 30) is as follows:
Program
A History of the Fire
Residents: $30 per year
Department in Fullerton
-------- --- Business $30 per year for every 10
Fire Explorer scout Post Owners/Managers: employees or portion thereof.
If you enroll after June 30, there is a $10 late fee and you will only
be covered for the remainder of that subscription year.
The subscription cost for residents covers you, and all members of
your household, for paramedic services. For businesses, the fee
provides paramedic services to you and your employees during
business hours only.
Please be aware that the Fullerton Paramedic Subscription Program
fee does not include ambulance costs. These fees are billed
separately by the ambulance company. The Fire Department
provides medical treatment to the patient and does not have an
ambulance for transportation; a separate company provides that
service.
The Program is only available to Fullerton residents and/or business
owners and their employees and the fee is non-refundable.
. Business Owner - Application
http://www.ci.fullerton.ca.us/fire/parasub.html 1/22/03 3
Paramedic Subscription Program-- City of Fullerton, CA., Page 2 of 3
- ATTACHMENT 1
. Business Owner - Renewal Application
. Care.Facility - Application
. Resident - Application
. Resident - Renewal Application
Frequently Asked Questions
. If I decide not to join the Paramedic Subscription Program,
what is the per call fee?
e What is the current annual subscription premium?
e Are visitors in my home covered?
. What is the coverage period?
. If I miss the enrollment deadline, may I still join?
. Can I join the program after using your services and have the
per call fee waived?
. Will my insurance cover the per call fee?
. Will you bill my insurance company if I use your services?
. If I have Medicare/Medi-Cal coverage am I covered?_
• If I join the program and move to another part of the city am
I still covered?
. If I join the program and then move from Fullerton will my
fee be refunded?
. Does the subscription fee include the cost of the ambulance?
Q: If I decide not to join the Paramedic Subscription
Program, what is the per call fee?
A: $200 for Basic Life Support and $300 for Advanced Life
Support.
Q: What is the current annual subscription premium?
A: $30 per household. You are covered anywhere within the
city limits.
Q: Are visitors in my home covered?
A: No. Only permanent residents of the household are
covered.
Q: What is the coverage period?
A: July 1 through June 30 of the following year. We do not
prorate the fee.
Q: If I miss the enrollment deadline, may I still join?
http://www.ci.fuHerton.ca.us/fire/pirasub.htm] 1/22/03 l_
Paramedic Subscription Program— City of Fullerton, CA Page 3 of 3
ATTACHMENT 1
A: Yes. There is an additional $10 processing charge.
Q: Can I join the program after using your services and
have the per call fee waived?
A: No. You must pay the per call fee. You may then join the
program.
Q: Will my insurance cover the per call fee?
A: Insurance coverage varies. You need to check with your
insurance company.
Q: Will you bill my insurance company if I use your
services?
A: No. The patient will need to file a claim with their insurance
company.
Q: If I have Medicare/Medi-Cal coverage am I covered?
A: No. Our services are not a benefit of their coverage plans.
Q: If I join the program and move to another part of the
city am I still covered?
A: Yes. You must notify the Fullerton Fire Department of your
new address.
Q: If I join the program and then move from Fullerton will
my fee by refunded?
A: No. The fee is non-refundable.
Q: Does the subscription fee include the cost of the
ambulance?
A: No. A separate company provides that service.
Heto I Contact/Feedback I Disclaimer I Home
Copyright 2001 City of Fullerton
Valid HTML 4.0
WX WAI-AA WCAG 1.0 Accessible to people with disabilities
http://www.ci.fullerton.ca.us/fire/parasub.html 1/22/03 S�
ATTACHMENT 2
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A7TAC000V ENT 3
CALIFORNIA
AMBULANCE
ASSOCIATION
JULY 11 2004
TO: CAA MEMBERS
FROM: David A. Nevins, President
RE: New Medicare Regional Fee Schedules and Temporary Rate
Increases Published in Federal Register - CALIFORNIA
PROVIDERS TO RECEIVE 38% INCREASE
In today's Federal Register, the Centers for Medicare and Medicaid Services (CMS)
published an Interim Final Rule implementing a new Regional Fee Schedule and
temporary increases to ambulance payment amounts. Some of the increases will affect
all ambulance services nationwide, some will affect ambulance services originating in
certain "super-rural" areas, and others will affect ambulance services in certain
geographic regions.
While the rules are immediately effective on July 1, 2004, CMS is accepting comments
until August 30, 2004. Attached as a pdf file is a copy of the Interim Final Rule.
The new regulations implement four changes brought about by Section 414 of the
Medicare Modernization Act(MMA) for the ambulance industry. All of these rate
increases affect only the fee schedule portion of the reimbursement. The four major
changes are:
1) An across-the-board increase of 1% for ambulance services originating in urban areas
and 2% for services originating in rural areas. Both of these increases apply to the fee
schedule portion of the base rate, and mileage. This across-the-board increase takes
effect on July 1, 2004 and should be automatically calculated by your carrier. This
temporary, across-the-board increase ends on December 31, 2006.
2) A 25% increase for mileage for miles 51 and greater--both for urban and rural
services. This temporary increase takes effect on July 1, 2004 and ends on December 31,
2008.
3) A temporary increase for ambulance services originating in "super-rural" areas.
"Super rural" areas are those in the lowest 25% of population density nationally. The
increase will be 22.6% of the fee schedule base rate for those services. Medicare will
determine which zip codes fall into the lowest quartile and will publish a revised zip code
file showing those areas.
- ATTACHMENT
4)A regional fee sche -ae that provides a floor amount for the. schedule portion of the
ambulance service base rates based on 9 geographic regions of the United States. If you
would receive more under the regional fee schedule formula than you would under the
original fee schedule,then you will be paid the higher of the two. In other words, no
ambulance service will lose reimbursement under a new regional fee schedule, and only
some will gain. The regional fee schedule areas and percentage increases are as follows
(please note, 4 of the regions have a 0% increase,which means they will continue to be
paid under the regular fee schedule):
Region 1 -New England (CT, ME,MA,NH, RI, VY) - 23.3% increase
Region 2 - Middle Atlantic (NJ, NY, PA) - 4.7% increase
Region 3 - East North Central (IN, IL, MI, OH, WI) - 0% increase
Region 4- West North Central (IA,KS, MN, MO,NE,ND, SD) - 0% increase
Region 5 - South Atlantic(DE, DC, FL, GA, MD,NC, SC, VA, WV) - 0% increase
Region 6 -East South Central (AL,KY, MS, TN) - 0% increase
Region 7 - West South Central (AR, LA, OK,TX) - 10.2% increase
Region 8 - Mountain(AZ, CO, ID,NM, MT,UT,NV, WY) - 9.9% increase
Region 9 Pacific (AK, CA, HI, OR,WA) - 38.6%increase
The regional fee schedule will be phased in throggh December 31, 2009. There will be a
"blend within a blend" for those services who will receive increases under one of the
regional fee schedules. In other words, your fee schedule portion will be a blend of the
National Fee Schedule and the Regional Fee Schedule. That blend for the fee schedule
portion of your payment will be:
7/1/04 - 12/31/04 - 80% Regional Fee Schedule and 20%National Fee Schedule
2005 - 60% Regional Fee Schedule and 40%National Fee Schedule
2006 -40% Regional Fee Schedule and 60%National Fee Schedule
2007 - 20% Regional Fee Schedule and 80%National Fee Schedule
2008 - 20% Regional Fee Schedule and 80%National Fee Schedule
2009 - 20%Regional Fee Schedule and 80%National Fee Schedule
2010 - 0%Regional Fee Schedule and 100%National Fee Schedule
While the increases implemented under the MMA should be automatically calculated by
NHIC, all ambulance services should take a few steps now with the implementation of
the MMA temporary increases:
1) Perform your own rate calculations-make sure you understand all of the temporary
increases, and perform your own rate calculations. Know what you are supposed to be
paid by the carrier, and be sure to monitor your EOBs for underpayments and
overpayments, and make the appropriate adjustments.
AA2) Revisit your rates -.,;member, Medicare will pay the lesser -your billed chargees d ENT 3
your Medicare-approved charge. Medicare will not automatically bump up your charges
so that you capture all of the revenue you are entitled to under the MMA. It is your
ambulance service's responsibility to ensure that your charges are higher than your
Medicare-approved rates. If you do not, you are leaving legitimate reimbursement on the
table!
3)Work with your billing company or billing agent- make sure your billing staff or
billing company is up to speed on the new MMA changes, so they can respond to
customer service inquiries, deal effectively with the carrier, and, most importantly,
collect all of the revenue to which your ambulance service is legitimately entitled!
This increase is a direct result of Congressman Thomas' efforts at the request of the CAA
to mitigate a more reasonable fee schedule for providers in California. While this
increase is only temporary, we will continue to work with Congressman Thomas and
others to assure providers in California are reimbursed on a permanent basis an equitable
rate by Medicare for the services provided.
We will keep you informed as further details develop on this matter. Any questions
should be directed to the attention of David A. Nevins, President via e-mail at
davnevins(c4ao1.com.
L,ity or r remoni. - raramecuc i dA
ATTACHMENT 4
The Cny Govern.mm of FreffwM CaUcmie _4'Y
Freff6nt
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0 About Fire Paramedic Tax
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0 Current News Property owners in Fremont have received property
0 Education tax bills that include the City's paramedic special tax.
0 Employment Below are some informative facts about this
0 Fire Safety Bond paramedic tax.
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0 Hazardous Materials What is the Paramedic Tax?
fb Paramedic Tax
>Frequently Asked The paramedic special tax is a voter-approved tax
Questions
•Prevention used to fund the Fire Department paramedic
•services program. It is used for training, equipment and
•Special Programs supplies. It appears on your property tax bill as
"Paramedic Supplement".
Back to Fire Home_ When was the Tax Approved?
The tax was approved on June 3, 1997, by more than 80% of Fremont's v(
IPD
Who Pays the Paramedic Tax?
Property owners in Fremont are subject to the special tax.
Employee Login
How Much Does the Paramedic Tax Cost?
The tax is based on a "benefit unit." A single family home is one benefit u
supermarket is four benefit units, etc. The FY2004/2005 tax rate for a sing
home is $13.50.
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AGREEMENT DESIGNATING AMBULANCE PROVIDER
NORTHERN AND CENTRAL AREA
This agreement, entered into on , by and
between the County of San Luis Obispo (hereafter "County") and San Luis Ambulance Service,
Inc., a California Corporation, (hereafter"the Contractor"),
WITNESSETH
WHEREAS, the County regulates the operation of ambulance providers pursuant to the
provisions of Chapter 6.60 of the San Luis Obispo County Code (hereafter "Chapter 6.60"); and
WHEREAS, the Contractor has been a licensed provider of ambulance services in San
Luis Obispo County for the past fifty seven (57) years; and
WHEREAS, on March 26, 1996,the County entered into a contract with the Contractor
designating the Contractor as the exclusive ambulance service provider in the Northern and
Central ambulance services areas of the County (hereafter"the 1996 Northern/Central Contract');
and
WHEREAS, on May 6, 1997, the County entered into a contract with Five Cities
Ambulance Service, Inc:designating said company as the exclusive ambulance service provider
in the Southern ambulance service area of the County(hereafter"the 1997 Southern Area
Contract'); and
WHEREAS, by 1999, Five Cities Ambulance Service, Inc. was experiencing financial
and operational problems that could only be cured by an infusion of capital; and
WHEREAS, the Contractor became the successor in interest of Five Cities Ambulance
Service, Inc. in 1999, subject to the approval of the County; and
WHEREAS, on March 14, 2000 , the County gave its approval of the Contractor's status
as the successor in interest of Five Cities Ambulance Service, Inc. On May 23, 2000, the County
approved amendments to both the 1996 Northern/Central Area Contract and the 1997 Southern
Area Contract to effectuate the transfer; and
WHEREAS, said amendments extended the duration of both contracts to make it feasible
for the Contractor to justify and recover the investments that would be necessary to upgrade the
operation of Five Cities Ambulance Service, Inc. to an acceptable level; and
WHEREAS, the 1996 Northem/Central Area Contract and the 1997 Southern Area
Contract contain somewhat varying provisions that create inefficiencies and inconsistencies; and
1
WHEREAS, to enhance efficiency and consistency, the County and the Contractor desire
to replace the two existing contracts with two new contracts, with substantially identical terms;
one covering the Northern and Central Ambulance Service Areas; and one covering the Southern
Ambulance Service Area; and
. WHEREAS, the parties also desire to define an objective process for periodic review of
the maximum rates that may be charged by the.Contractor, as set forth below; and
WHEREAS, the parties desire to clarify the language of the former contracts and to make
certain other technical changes to this agreement as set forth below; and
WHEREAS, Chapter 6.60 defines the process for the development of ambulance provider
agreements and selection of providers Whereby ambulance providers are designated by agreement
between County and the designated provider,and
WHEREAS, the Ambulance Performance/Operations Committee (hereafter"APOC")
established pursuant to Chapter 6.60 has reviewed this agreement and recommended that County
enter into this agreement with the Contractor for the provision of ambulance services;
NOW, THEREFORE, in consideration of the provisions set forth below,the parties
hereby agree as follows:
ARTICLE 0.5 TRANSITIONAL PROVISIONS
Effective Date. This contract shall be effective upon the date (hereafter"the Effective
Date") which is the latter of(1) the date that it is executed by the Contractor and(2)the date of
the Board of Supervisors meeting at which it is approved.
Rights and Obligations with Respect to the Provision of Ambulance Services from and
after the Effective Date. This agreement governs the rights and obligations of the County and the
Contractor with respect to ambulance services provided from and after the Effective Date.
Neither the 1996 Northern/Central Area Contract'nor the 1997 Southern Area Contract shall have
any effect on said rights and obligations.
Rights and Obligations with Respect to the Provision of Ambulance Services Before the
Effective Date. This agreement shall have no effect on the rights and obligations of the County or
the Contractor with respect to ambulance services provided before the Effective Date. The 1996
Northern/Central Area Contract and the 1997 Southern Area Contract shall continue to define the
rights and obligations of the parties with respect to ambulance services provided before the
Effective Date.
ARTICLE 1. DEFINITIONS
For the purpose of this agreement, all words and phrases that are defined in section
6.60.010 of the San Luis Obispo County Code shall have the meaning ascribed to them in said
section of the County Code and are incorporated herein by reference. The following words and
phrases that are not defined in section 6.60.0 10 shall have the following meaning:
Advanced Life Support(ALS): For ambulance services, means special services
designed to provide definitive prehospital emergency medical care, including but not limited to,
cardiopulmonary resuscitation, cardiac monitoring, cardiac defibrillation, advanced airway
management,intravenous therapy, administration of specified drugs and other mechanical
preparations, and other medicinal preparations, and other specified techniques and procedures
administered by authorized personnel under the direct supervision of a base hospital as part of the
local EMS system at the scene of an emergency during transport to an acute care hospital and
during interfacility transfer.
ALS Provider: A public or private provider officially designated by the County Health
Officer as an entity authorized to operate ALS Units and provide ALS services in San Luis
Obispo County.
APOC: The San Luis Obispo County Ambulance Performance/Operations Committee,
created pursuant to section 6.60.050 of Chapter 6.60.
Ambulance Service Area: The Northern, Central, and Southern Ambulance Service
Areas are the geographical areas of the County that are separately defined in Exhibit A, attached
hereto and incorporated herein by this reference. This agreement shall cover services in the
Northern and Central Ambulance Service Areas.
Basic Life Support (BLS): Emergency first aid and cardiopulmonary resuscitation
procedures which as a minimum include recognizing respiratory and cardiac arrest and starting
the proper application of cardiopulmonary resuscitation to maintain life without invasive
techniques until the victim may be transported or until advanced life support is available.
Chapter 6.60: Chapter 6.60 of the San Luis Obispo County Code("Prehospital
Emergency Medical Care and Transport Services").
Contract Manager: The County's Public Health Agency Director, or designee, or
successor in responsibility.
County: The County of San Luis Obispo.
Emergency: A condition or situation in which an individual has a need for immediate
medical attention or where the potential for such need is perceived by emergency medical
personnel or a public safety agency.
EMS Act: California Health and Safety Code Sections 1797 et seq., or successor
legislation on the same subject.
EMSA,Inc.: The San Luis Obispo Emergency Medical Services Agency, Inc., a
California nonprofit corporation. SMSA, Inc. is not the Local EMS Agency but it does perform
certain functions for the Local EMS Agency pursuant to a contract with the County.
EMS System: A system of organizations, resources and individuals from whom some
action is required to ensure a timely and medically appropriate response to medical emergencies.
First Response Organization: Typically a public agency, such as a fire department, that
responds to emergency calls for medical assistance,providing initial stabilization and trained
assistance on-scene and, when required, en route to medical facilities; also refers to certain .
extrication and rescue services. In accordance with priority dispatch protocol, a first response
unit is routinely sent to all presumptively classified life-threatening calls within the ambulance
Contractor's service area.
Incident Command System: The combination of facilities equipment,personnel
procedures, and communications operating within a common organizational structure, with
responsibility for the management of assigned resources to effectively accomplish stated
objectives pertaining to an incident.
Life Threatening Emergencies: Those situations determined in accordance with local
medical direction that are likely to result in the loss of life without immediate intervention.
Local EMS Agency: The Public Health Agency of the County of San Luis Obispo,
under the direction of the Public Health Agency Director, or its successor in responsibility (in the
event of a reorganization affecting the Public Health Agency).
Local EMS Plan: The emergency medical services plan adopted by the Local EMS
Agency pursuant to the requirements of the EMS Act.
Medical Control: The medical management of the emergency medical services system
pursuant to the provisions of Health& Safety Code chapter 5, sections 1978 et seq.
Non-Life Threatening Emergencies: Those medical emergencies determined in
accordance with local medical direction,not likely to result in the loss of life.
Public Health Agency Director: The Public Health Agency Director of San Luis
Obispo County.
Medical Director: The physician under whose license and authority EMTs and
Paramedics provide services.
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Paramedic: An individual trained and licensed to perform advanced life-support
procedures under the direction of a physician.(Also referred to as an EMT-P.)
Paramedic Ambulance: An ambulance staffed by a minimum of one licensed
paramedic and one certified EMT and equipped to provide advanced life support (ALS).
Transport: When a patient is transported by ambulance to a hospital or between medical
facilities where the medical capabilities of an ambulance are required or potentially required.
ARTICLE 2. DESIGNATION AS PROVIDER AND
DESCRIPTION OF SERVICES TO BE PROVIDED
2.1 Services-In General. Pursuant to Chapter 6.60, the County hereby designates the
Contractor as the Ambulance Service Provider for the Northern and Central.Ambulance Service
Areas. Within each of the Ambulance Service Areas, the Contractor shall provide emergency
ambulance service without interruption, 24 hours per day, every day, for the full term of this
contract, in accordance with all provisions of this contract. The Contractor shall provide said
emergency ambulance services without regard to the patient's race, color, national origin,
religious affiliation, age, sex, or ability to pay.
2.2 Applicable Standards and Involved Agencies. The Contractor shall provide
Advanced Life Support ("ALS") emergency ambulance services under Medical Control as
dispatched by MED-COM. Such services shall be provided in accordance with the requirements
of the EMS Act, Chapter 6.60, the Local EMS Plan, this contract, and any other applicable
statutes, ordinances and regulations. In performing services hereunder, the Contractor shall work
cooperatively with the Local EMS Agency. The Contractor shall also cooperate with APOC and
EMSA, Inc. with respect to matters within their purview.
2.3 Air Ambulance Transport. The County reserves the right to enter into separate
transport agreements with air ambulance providers. Notwithstanding any other provision of this
Agreement, the County may provide for air transport of patients when such transportation is
deemed by the most senior medical personnel on the scene to be in the best interest of the
patient(s).However, no such agreement shall provide for air transport of non-critical patients or
of critical patients when a ground ambulance is on-scene and transport time by ground
ambulance to the most accessible emergency medical facility equipped, staffed, and prepared to
administer care appropriate to the needs of the patient is the same or less than the estimated air
transport time.
2.4 Non-Profit Transport Services. The County reserves the right to enter into separate
agreements with non-profit agencies or districts whose purpose is to reduce the travel time for
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patients residing in the more rural or inaccessible areas of the County. Such agreements will be
structured.so as to insure that the Contractor will be involved in meeting non-profit transport
agencies at pre-determined transfer points for the transfer of patient care to the Contractor. Such
plans will be developed under the approval of the Local EMS Agency.
2.5 Requirement for Non-Emergency Ambulance Services: It is the intent of the Local
EMS Plan and related ambulance provider agreements to establish Exclusive Operating Areas
("EOA")within which the designated ambulance service provider will retain the authority and
responsibility for the provision of all ambulance services in the EOA. When requests for non-
emergency ambulance transport service are made, the Contractor may take the time necessary to
mobilize resources beyond those on-duty at the time of the request. However, at any time,the
lead medical personnel at the scene of the patient requiring transport (typically a hospital or
hospital emergency room)may upgrade the patient's status to one requiring emergency medical
transport. At that time, the designated Contractor in that EOA must respond immediately, as they
would for any emergency request.
ARTICLE 3. PERFORMANCE STANDARDS
3.1 Deployment Plan. Throughout the term of this agreement, the Contractor shall
comply with the specific deployment plan requirements contained in Exhibit B, attached hereto
and incorporated herein by this reference, specifying all the ambulance stations (general
locations) and the number of vehicles to be deployed during each hour of the day, and each day
of the week for each specific area or zone.
The general goal of the Deployment Plan is to provide an Advanced Life Support(ALS)
unit, either by the Contractor or by an ALS fire service agency,to at least 90% of all potentially
life threatening emergency ambulance requests originating within each Ambulance Service Area
with a maximum response time of 10 minutes in areas designated urban, and a maximum
response time of 30 minutes in areas designated as rural, and a maximum response time of 60
minutes in areas designated as remote. The various areas are set forth in Exhibit A, attached
hereto and incorporated herein by this reference.
Upon request,for purposes of contract administration, the Contractor shall provide* .
documentation regarding the degree to which it has complied with the deployment plan.
(Deployment plan specifics for each zone are found in Exhibit B).
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3.2 Staffing and Personnel. The Contractor shall send a Paramedic Ambulance staffed
with a minimum of two personnel, whose level of certification shall, as a minimum, be one
Emergency Medical Technician-I (EMT-I) and one Emergency Medical Technician-Paramedic
(EMT-P)to all life threatening and potentially life threatening emergency medical requests.
Specific certification, training, supervision and preparedness requirements are outlined below.
A. Certification. All of the Contractor's ambulance personnel responding to
emergency medical requests shall be currently certified and/or licensed by both the State of
California and the Local EMS Agency. In addition, all of the Contractor's EMT-Ps shall be
currently accredited by EMSA, Inc. to practice in San Luis Obispo County. The Contractor shall
retain on file at all times copies of the required current and valid licenses, certifications, and/or
accreditations of all emergency medical personnel performing services under this Agreement.
B. Reasonable Work Schedules and.Working Conditions. As an independent
Contractor, the Contractor shall be responsible for determining the methods and techniques for
achieving compliance with the requirements of this contract; provided, however, that the
Contractor shall utilize reasonable work schedules and work periods for its personnel so that they
are fresh enough to be able to perform safely and to provide adequate patient care. The
Contractor shall ensure that any of its personnel who work extended shifts, part-time jobs,
voluntary overtime, or mandatory overtime, are not exhausted to such an extent that their
judgment or motor skills might be impaired. With the exception of extreme emergencies, the
Contractor shall not knowingly allow its personnel to work at any provider(public or private) in
excess of seventy-two(72) consecutive hours. The Contractor must provide each and every one
of its ambulance personnel with no less than twenty-four(24) hours of off-duty time,
immediately following each work period.
C. Required Hazardous Materials Training. The Contractor shall staff each
ambulance with paramedics and EMT's who shall, within ninety(90) days of hire by Contractor,
each show sufficient evidence that they have successfully completed "Hazardous Materials—First
Responder Operational Course", or training that has been accepted as equivalent by EMSA, Inc.
and the County Fire Chiefs Haz-Mat Committee.,
D. Orientation and On-Going Preparedness. The Contractor shall properly orient
all field personnel before assigning them to respond to emergency medical requests. Such
orientation shall include at a minimum,provider agency policies and procedures; EMS system
overview;EMS policies and procedures; radio communications with and between the provider
agency,base hospital,protocols with other agencies (fire service, Sheriff/Coroner), receiving
hospitals, and County communications centers; map reading skills including key landmarks,
routes to hospitals and other major receiving facilities within the County and in surrounding
areas; and ambulance and equipment utilization and maintenance.
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E. Field Supervision. The Contractor shall provide at all times and within San
Luis Obispo County an individual authorized to act on behalf of the Contractor in all operational
matters.
F. Preparation for Multi-casualty Response. The Contractor shall train all
ambulance personnel and supervisory staff in their respective roles and responsibilities under the
County of San Luis Obispo Disaster Plans which are on file at the Local EMS Agency and
prepare them to function in the variety of roles that are required within the Incident Command
System.
G. Critical Incident Stress Debriefine. The Contractor shall make available to all
Contractor employees the San Luis Obispo County Fire Chiefs Critical Incident Stress Debriefing
Program. The Contractor shall encourage program/team participation by the Contractor's
employees. The Contractor shall contribute up to $750 per zone per year to the Fire Chiefs
Association, upon their request, to assist in funding the program/team. The Contractor shall not
be required to contribute such funds for any purpose other than ongoing training and support that
is directly linked to the program/team's needs.
H. Training with Fire Agencies. The Contractor shall ensure that its ambulance
crews make themselves available to train with fire agencies located within all service areas
covered by this contract, engaging in joint training with each local fire department at least twice
each calendar year.
I. Communication with Fire.A eg ncies.The Contractor shall ensure that its
Operations Manager makes himself or herself available to meet with fire chiefs from public
agencies located within the Ambulance Service Area on a quarterly basis. The Contractor shall
schedule these meetings with reasonable notice to the fire chiefs.
3.3 Vehicles and Equipment.
A. Vehicles. Ambulance vehicles shall at a minimum meet the standards of Title
XIII, California Code of Regulations. Vehicles shall display the "911" emergency telephone
number and state the level of service, "Paramedic Unit", on both sides and the unit identification
number/radio designation in 4" letters. Ambulance vehicles shall be marked to identify the
company name, but shall not display any telephone number other than 911 or any other
advertisement. The Contractor shall maintain its vehicles in a good working order, consistent
with the manufacturer's specifications. In addition, detailed records shall be maintained as to
work performed, costs related to repairs, and operating and repair costs analyses where
appropriate. Reports shall be accomplished and systems shall be maintained so as to achieve at
least the industry norms in vehicle performance and reliability.
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B. General Equipment. All of the Contractor's ambulances shall carry all
emergency supplies and equipment identified in the County Ambulance Equipment and Supply
Policy on file at the Local EMS Agency on each of the licensed units. The Contractor shall
maintain its vehicles, equipment, and supplies in a clean, sanitary, and safe mechanical condition
at all times. The Contractor agrees that equipment and supply requirements may be changed with
the approval of the Contract Manager due to changes in technology.
C. Communications Equipment and Dispatch. The.Contractor shall equip all
paramedic ambulances and supervisory vehicles used in providing service with a County Med-
Com-capable radio. Each ambulance and supervisory vehicle shall also be equipped with a
cellular telephone. All ambulances for emergency medical.response under the terms of this
Agreement shall operate only within San Luis Obispo County, oras directed by the San Luis
Obispo County communications.center, or in compliance with policies and protocols established
by the County. UHF and VHF radio frequencies shall be designated by the County. The
Contractor shall operate the two-way radios in conformance with all applicable rules and
regulations of the Federal Communication Commission, and in conformance with all applicable.
state and/or County rules and operating procedures.
D. Failure To Meet Minimum In-Service Equipment/Supply Requirements The
County may inspect the Contractor's ambulances during normal business hours,with prior
notice. Any ambulances that fails to meet the minimum in-service requirements contained in the
County Ambulance Equipment and Supply Policy, as determined by the County, shall be
immediately removed from service until the deficiency is corrected, and shall be replaced as
necessary to ensure continued compliance with the deployment requirements contained in
Exhibit B.
E: Equipment Exchange and-Replacement. The Contractor shall implement and
maintain inventory control and equipment maintenance systems which keep the ambulance fleet
fully stocked with approved equipment in good working order at.all times. The Contractor shall
establish a mechanism to replenish disposable medical supplies and equipment used by a public
first responder agency in connection with each patient transport.
F. Ambulance Restocking Program. The Contractor shall develop and implement
a restocking plan for all first responders in all service areas within the County. Said restocking
plan shall be approved by the Health Director and EMSA and implemented by the Contractor
within 120 days from the Effective Date of this Agreement.
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G. Dailv Ambulance and Equipment Inspection and Check-Out.Each day, each
ambulance unit and the equipment contained therein shall be inspected and checked out. Each
ambulance unit shall be restocked following each response, except in cases where back-to-back
responses don't allow for restocking prior to initiating the second response. Equipment and
supplies shall be maintained at levels that assure that back-to-back responses do not cause an
ambulance unit to respond to an emergency medical call without sufficient equipment and
supplies.
3.4 Disaster,Multi-casualty,Mutual Aid Response and.Standby. The Contractor will
deploy resources in accordance with.emergency and or mutual aid plan or plans approved by the
County. The Contractor shall render emergency assistance in Multi-casualty or disaster situations
to any location as directed by the San Luis Obispo County communications center. At the scene.
of the Multi-casualty incident or disaster, the Contractor's personnel shall perform in accordance
with the County's Emergency Response Plans and the Incident Command System. When the
Contractor is notified that Multi-casualty/disaster assistance is no longer required,the Contractor
shall return all of its resources to the primary area of responsibility and shall resume all
operations in a timely manner. During the course of the Multi-casualty/disaster,the Contractor
shall use its best efforts to provide local standard emergency coverage by providing back lip
units.
A. Trainin . The Contractor shall participate in disaster and multi-casualty
training and exercises conducted by SMSA, the County and fire service agencies as requested.
B. Stand-By Service. The Contractor shall provide., at no charge to the County or
requesting agency, stand-by services at the scene of an emergency incident within its Ambulance
Service Area when directed by a County communications center upon the request of a public
safety agency.The Contractor may charge for stand-by at an incident where a responsible party
exists.
3.5 Move Up and Cover. The Contractor shall provide ambulance move-up and
coverage for service areas left uncovered due to other emergency responses, as directed by the
County's communications center. Nothing shall preclude Contractors in each service area from
developing mutual coverage agreements that may or may not involve financial remuneration.
When a Contractor provided inter-service area coverage at the request of the County
communications, Contractor shall be exempt from normal zone coverage requirements.
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ARTICLE 4. FIRST RESPONDER SUPPORT
4.1 Utilization of Fire Department Personnel. The County and the Contractor
acknowledge that fire service personnel play an integral part of the County's EMS System. They
are involved in scene management, patient care at both ALS and BLS levels, auto extrication,
heavy rescue and cliff/wilderness rescue and assistance in patient transportation. The number
and type of resources required of Contractor for each zone have been configured around the
participation of the various fire service resources within the zone. If a public agency providing
fire-based first responder services executes a separate agreement with Contractor generally
assigning to Contractor its right to bill patients for first responder services, Contractor shall pay
the first responder agency for said assignment of billing rights in accordance with section 4.2
below. In order to be eligible for support fees, fire service agencies must meet minimum ALS
requirements or EMT-D qualifications as outlined by the Local EMS Agency.
4.2 Timing and Amount of First Responder Payments.The Contractor shall make the
first responder payments shown in Exhibit C, attached hereto, and incorporated herein by this
reference, to the agencies identified in Exhibit C, in the amounts shown in Exhibit C. Payments
by Contractor to the first responder public agencies identified in Exhibit C shall be made in four
equal quarterly installments, due to the first responder fire agencies by the last business day of
the second month of the following quarter(for example, payment for the period of April ?
through June 30'will be due on or before the following August 30`h).
4.3 Annual Adjustment to Payments. Payments to the public agencies listed in Exhibit
C will be adjusted annually, effective on July 1,2003 and annually thereafter, in proportion to
the change in the Los Angeles-Long Beach-Anaheim Consumer Price Index. However, in no
event shall the annual increase exceed five percent(5%). The indexes shall be for All Urban
Consumers as published by the Bureau of Labor Statistics.
4.4 Independent Agreements with Other Agencies.Nothing in this agreement shall
preclude Contractor from entering into other agreements with local fire service agencies to
improve the EMS system's overall efficiency. Any such agreement must be approved by the
County's Ambulance Performance/Operations Committee.
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ARTICLE 5. RECORDS,REPORTING AND INSPECTIONS
5.1 EMS Run Report. The Contractor shall utilize the County's approved format for
documentation on all patient responses, including non-transports. The Contractor shall complete
this form accurately and include all information listed in Section 100169 of the California Code
of Regulations, and distribute it according to the Local EMS Agency's Policies and Procedures.
The Contractor shall purchase any required forms. At the Contractor's option, the Contractor
may print its own supply of forms. All forms are subject to revision by the Local EMS Agency at
any time. The Contractor shall provide the County with copies of individual EMS run reports as
requested by Contract Manager. When so requested, reports shall be provided by the Contractor
to the Contract Manager within three (3) business days of the request. The County will limit such
requests to circumstances that merit special handling.
5.2 Personnel Reports. The Contractor shall provide the Local EMS Agency with a list
of EMS personnel currently employed by the Contractor and shall update that list whenever there
is a change. The personnel list shall include, at a minimum, the name, address,telephone
number, Paramedic;CPR and ACLS expiration dates, and California Driver's License number of
each person on the list.
5.3 Audits and Inspections. The Contractor shall maintain separate business and
financial records for services provided pursuant to this Agreement in accordance with generally
accepted accounting principles. The County shall have the following rights of audit and
inspection:
A. Inspection and Copying. Upon reasonable advance notification, during normal
business hours, the County shall have the right to review any and all of the Contractor's business
and financial records pertaining to this Agreement. All such records shall be made available to
the County at their San Luis Obispo County office or other mutually agreeable location. The
County may audit, copy,make transcripts, or otherwise reproduce such records,including but not
limited to contracts, payroll; inventory,personnel and other records, daily logs, and employment
agreements.
B. Financial Statements. Annually, the County may require the Contractor to
obtain and provide the County with financial statements. If the Contractor has audited financial
statements in his possession, he shall make those available to the County. Otherwise,the
financial statements shall be prepared by a Certified Public.Accountant and shall comply with
generally accepted standards for Reviewed Financial Statements. The financial statements shall
cover the Contractor's ambulance operations and/or any other businesses that share overhead
with the Contractor's ambulance service operation.
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C. Records of Billing. The Contractor may be required by the County to provide
the County with periodic report(s) in the format approved by the Contract Manager to
demonstrate billing compliance with approved/specified rates.
D. BudQetForecasts and Other Reports. The Contract Manager may require the
Contractor to assist in future budget forecasting for planning purposes. The Contractor shall
provide the County with such other reports and records as may be reasonably required by
Contract Manager.
E. Observation of Operations. Contract Manager or his/her representatives may, at
a mutually agreed upon time, directly observe.the Contractor's control center operations,
maintenance facilities, and ambulance post locations, and may ride as "third person" to observe
the operation of any of the Contractor's ambulance units. The Contract manager or his/her
representative shall conduct themselves in a professional and courteous manner, shall not
interfere with the Contractor's employees in the performance of their duties, and shall at all times
be respectful of the Contractor. The Contractor shall submit to an annual performance evaluation
in accordance with procedures established by Contract Manager. It is also understood that at any
time the County may cause to be monitored the response time of any ambulance crew, so as to
ascertain compliance with standards that are established in Article 3 of this agreement..
ARTICLE 6. PATIENT CHARGES
6.1 Charges for Services Provided.The Contractor's patient charges for services
provided pursuant to this Agreement shall not exceed the rates set forth in Exhibit.D, attached
hereto and incorporated herein by this reference, except as said rates are modified pursuant to the
provisions of this Article.
A. Annual Increases in Charges. Annual increases in patient charges identified in
Exhibit D will be effective on.January 1 of each calendar year during the tern of this agreement.
The increase will be based upon the percentage increase of the Los Angeles-Long Beach-
Anaheim Consumer Price Index_. However, in no even shall the annual increase exceed five
.percent(5%). The indexes used shall be for All Urban Consumers as published by the Bureau of
Labor Statistics.
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B. Significant Changes in Financial Conditions. In the event that Contractor
experiences increases/decreases in operating costs or increases/decreases in operating revenues to
the extent that Contractor is no longer earning a reasonable return on investment, County will
consider an increase in patient charges above and beyond the annual increases specified in 6.LA.
above. In this situation, the Contractor Manager may require Contractor to provide County with
financial statements and/or other pertinent information necessary to support any recommenced
supplemental increase in patient charges. Any such change in patient charges must be approved
by the County Board of Supervisors.
6.2 Periodic Rate Reviews -When Allowed. There shall be regular,periodic reviews of
the maximum rates that the Contractor is allowed to charge at the following times or under the
following circumstances:
A. Review of Contractor's Fiscal Year Ending September 30..2001. There shall
be a rate review for Contractor's fiscal year ending on September 30, 2001 for the purpose of
reviewing the rates set forth in Exhibit D, said rates having been set at levels slightly less than the
rates that were charged during that fiscal year.
B. Annual Review at Option of Either Party. Either party shall have the right, in
its complete and absolute discretion, to require a rate review for the prior Contractor fiscal year
ending September 30, 2002, and every year thereafter, by serving a written request for a rate
review on the other party within 30 days of the end of that fiscal year. A rate review shall be
conducted whenever such a request is served in a timely manner.
C. Review Due To Significant Unexpected Development. If there is an
unexpected development that would have a major impact on either the expenses or income of
Contractor, either party may request a rate review within a reasonable time after the impact of
that development becomes known. The party requesting the rate review shall support its request
with a description of the unexpected development and its estimated impact upon the expenses or
income of Contractor. The party receiving the request for rate review shall grant the request if it
appears that it may be meritorious. Neither party may unreasonably deny a request for such a rate
review.
6.3 Periodic Rate Reviews- Disclosure of Records. When.a rate review is initiated
pursuant to section 6.2 above, Contractor shall provide any requested business records and
reviewed financial statements to the County, covering the period in question, said records and
statements to be provided within 90 days of the receipt of the written request.
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6.4 Periodic Rate Reviews-Findings by the County. The County, shall review the
records and statements submitted by Contractor and verify the accuracy thereof. The County
may require submission of confirming documentation. At the conclusion of its review, the
County shall ascertain the value of the following terms, which shall have the meaning set forth
below:
A. Allowable Annual Expense: The total of expenses that were verified and that
the County found were reasonably necessary to the performance of the contract. The parties .
agree that the following expenses (if incurred) are examples of expenses that would not be
reasonably necessary to the performance of the contract: (i) charitable donations, (ii) political
contributions, and(iii) excessive compensation paid to the principal shareholders of the
corporation, i.e., compensation in excess of the level reasonably necessary to retain competent
individuals to perform the duties and responsibilities assigned to said principal shareholders.
B. Effective Annual Profit:The amount ofprofit found by the County, including
any items that Contractor reported as expenses but were disallowed by the County pursuant to the
preceding subparagraph.
C. Effective Profit Marein:.The Effective Annual Profit divided by the Allowable
Annual Expense, expressed as a percentage.
6.5 Periodic Rate Reviews Setting Future Maximum Rates.The County shall allow
Contractor a reasonable rate of return, and County agrees to consider all rate review applications
in a timely manner. The County shall use the information developed in the rate review to predict
the Effective Profit Margin over the next 12 months (hereafter "the Predicted Future Effective
Profit Margin"). The prediction shall be made by assuming that rates are unchanged and
estimating the Effective Profit Margin over the next 12 months, considering(1)the rate review
data, which shall be used as a baseline, (2)general historical trends that are likely to affect
revenue and expense, and(3) specific, one-time factors that are likely to cause atypical changes
in revenue and expense. The Predicted Future Effective Profit Margin shall be deemed to be
reasonable rate of return if it falls within the range between 9% and 12%,which shall be referred
to as the "Target Profit Range."
A. Predicted Future Effective.Profit Margin Within Target Profit Range. If the
Predicted Future Effective Profit Margin falls within the Target Profit Range, no change in future
maximum rates shall be made as a result of the rate review.
B. Predicted Future Effective Profit Margin Outside the Target Profit Range. If
the Predicted Future Effective Profit Margin is outside(above or below) the Target Profit Range,
the future maximum rates shall be adjusted(upward or downward)by amounts sufficient to bring
the Predicted Future Effective Profit Margin within the Target Profit Range for the future.
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6.6 Billing and Collections. The Contractor shall operate a billing and accounts
receivable system that is well documented, easy to audit, and which minimizes the effort required
of patients to recover payment from third party sources for which they may be eligible. The
Contractor shall make no attempts to collect its fees at the time of service.
ARTICLE 7. TERM AND TERMINATION
7.1 Initial Term. Unless terminated by either party pursuant to the provisions of this
agreement, this Agreement shall remain in effect for the time period (hereafter"the Initial Term")
beginning on the Effective Date and ending on March 31, 2010.
7.2 Automatic Extension of Term.Unless terminated by either party pursuant to the
provisions of this agreement before March 31,2010, the Agreement shall automatically be
extended and remain in effect until March 31, 2011 (the additional twelve months being the
"First Extension"). Further, the agreement may thereafter be extended for an additional term(the
"Second Extension"),not to exceed thirty-six (36) months,by mutual agreement of the parties.
Said mutual agreement must be reached prior to the end of the First Extension.
73 Termination by Either Party By Mutual Consent. This agreement may be
terminated on less than 365 days advance written notice, by written mutual consent.
7.3 Termination by the County for Cause. County shall have the right to terminate this
Agreement or to pursue any appropriate legal remedy in the event the Contractor materially
breaches this Agreement and fails to correct such default within thirty(30) days following the
service of a written notice by the County specifying the default(s) and the effective date of .
intended termination of this Agreement; absent cure. Conditions and circumstances which shall
constitute a material breach by the Contractor shall include but are not limited to the following:
A. Failure of the Contractor to operate the ambulance service system in a manner
which enables the County and the Contractor to remain in substantial compliance with the
requirements of the applicable Federal, State, and County laws,rules, and regulations. Minor
violations of such requirements shall not constitute a material breach except serious, willful
and/or repeated violations shall constitute a material breach;
B. Falsification of data supplied to the County including by way of example but
not by way of exclusion, dispatch data,patient report data,response time data, financial data, or
falsification of any other data required under this Agreement;
C. Failure to maintain equipment in accordance with good maintenance practices;
D. Deliberate and unauthorized scaling down of operations to the detriment of
performance;
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E. Attempts by the Contractor to intimidate or otherwise punish employees who
desire to sign contingent employment agreements with competing bidders during a subsequent
bid cycle;
F. Attempts by the Contractor to intimidate or punish employees who participate
in protected concerted activities, or who form or join any professional associations;
G. Chronic and persistent failure of the Contractor's employees to conduct
themselves in a professional and courteous manner, or to present a professional appearance;
H. Failure to comply with approved rate setting, billing, and collection .
procedures;
I. Repeated.failures to meet response time requirements after receiving notice of
non-compliance from the Contract Manager;
J. Failure of the Contractor to provide and maintain the required insurance and
performance security bond.
ARTICLE 8.ASSIGNMENT OF BILLING RIGHTS
WITH RESPECT TO COUNTY-PROVIDED FIRST RESPONDER SERVICES
8.1 Assignment. The County hereby assigns to the Contractor its right to directly bill
persons for County-provided first response emergency medical services. First response
emergency medical services provided by the County may include, but are not limited to,
providing initial stabilization and trained on-scene assistance, and assistance en route to medical
facilities as required, and extrication and rescue services.
8.2 Payment for Assignment. In consideration of the assignment set forth in paragraph
8.1 above,the Contractor shall pay to the County a "first responder support" payment in
accordance with Article 4 above.
ARTICLE 9.MISCELLANEOUS
9.1 Independent Contractor. The parties acknowledge and agree that the Contractor is
an independent Contractor of the County and that nothing herein shall be construed as creating
any other type of relationship between the County and the Contractor.
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9.2 Performance Bond. The Contractor has furnished the County with a Performance
Bond in the amount of Five Hundred Thousand Dollars (S500,000), which has been approved by
the County prior to the date of execution of this agreement. Any succeeding Performance Bond
shall be substantially equivalent to Exhibit E, attached hereto and incorporated herein by this
reference, and shall be written by a company authorized to do surety business in the State of
California with a minimum of a"B" rating and of adequate financial category as rated by the
current edition of Best's Key Rating Guide, as published by A.M. Best Company, Oldwick, New
Jersey 08858. The County agrees that Contractor may utilize said Performance Bond to comply
with other County Contracts.
9.3 Insurance. During the entire term of this Contract and any extension or modification
thereof; the Contractor shall keep in effect insurance policies meeting the following insurance
requirements unless otherwise expressed in the Special Conditions:
A. Liability Insurance. The Contractor shall provide comprehensive liability
insurance, including coverage for owned and non-owned automobiles,with a minimum
combined single limit coverage of$1,000,000 for all damages, including consequential damages,
due to bodily injury, sickness or disease, or death to any person or damage to or destruction of
property, including the loss of use thereof, arising from each occurrence. Such insurance shall be
endorsed to include the County and its officers and employees as additional insureds as to all
services performed by the Contractor under this agreement. Said policies shall constitute primary
insurance as to the County, the State and Federal Governments, and their officers, agents, and
employees, so that other insurance policies held by them or their self-insurance program(s) shall
not be required to contribute to any loss covered under the.Contractor's insurance policy or
policies..
B. Workers' Compensation. The Contractor shall provide and maintain
throughout the.term of this agreement workers' compensation insurance coverage for its
employees.
C. Certificate of Insurance. The Contractor shall provide the County with (a)
certificate(s) of insurance evidencing liability and worker's compensation insurance as required
herein no later than the effective date of this Contract. If the Contractor should renew the
insurance policy(ids)or acquire either a new insurance policy(ies) or amend the coverage
afforded through an endorsement to the policy at any time during the term of this Contract, then
the Contractor shall provide (a) current certificate(s) of insurance.
D. Additional Insurance Provisions. The insurance policies provided by the
Contractor shall include a provision for thirty (30) days written notice to the County before
cancellation or material changes of the above specified coverage.
18
9.4 Indemnification. The Contractor shall defend, indemnify, save, and hold harmless
the County and its officers and employees from any and all claims, costs and liability for any
damages, sickness, death,or injury to person(s) or property, including without limitation all
consequential damages, from any cause whatsoever arising, directly or indirectly from or
connected with the operations or services of the Contractor or its agents, servants, employees or
subcontractors hereunder; save and except claims or litigation arising through the sole negligence
or sole willful misconduct of the County or its officers or employees. The Contractor shall
reimburse the County for any expenditures, including reasonable attorneys' fees, that the County
may make by reason of the matters that are the subject of this indemnification.
9.5 Modifications and Amendments.
A. General Amendments. This Contract may only be modified or amended by a
written document executed by the Contractor and the San Luis Obispo County Board of
Supervisors or,after Board approval, by its designee, subject to any required State or Federal
approval.
B. Administrative Amendments. To the extent required by changes in applicable
State or Federal laws or regulations,this Agreement shall be automatically amended to conform.
9.6 Entire Agreement. This Contract contains all the terms and conditions agreed upon
by the parties. Except as expressly provided herein, no other understanding, oral or otherwise,
regarding the subject matter of this Contract shall be;deemed to exist or to bind any of the parties
hereto:
9.7 Notices. Any notice required to be given pursuant to the terms and provisions hereof
shall be,in writing and shall be sent by certified or registered mail to the parties at the following
addresses, as maybe amended from time to time:
To the Countv: To_the.Contractor:
Public Health Agency Director Frank I. Kelton,President and CEO
County of San Luis Obispo San Luis Ambulance Service, Inc.
2180 Johnson.Avenue P.O. Box 954
San Luis Obispo, CA 93401 San Luis Obispo, CA 93406
With a Copy toa
P. Terence Schubert, Esq.
Attorney at Law
1254 Marsh Street
San Luis Obispo, CA 93401
19
IN WITNESS WHEREOF, the parties have executed this Agreement as of the date first set forth
above.
SAN LUIS AMBULANCE SERVICE, INC.
A California Corporation
By:
Frank I. Kelton
President and CEO
ATTEST:
(Signature)
Name and Title of Person Attesting for
San Luis Ambulance Service, Inc.
COUNTY OF SAN LUIS OBISPO
By:
Chairman of the Board of Supervisors.
Authorized by Board Action on:
APPROVED AS TO FORM
AND LEGAL EFFECT
JAMES B.LINDHOLM, JR.
COUNTY COUNSEL
By- _
Deputy County Counsel
Dated:
20
ATTEST:
JULIE RODEWALD, County Clerk and
Ex-Officio Clerk of the Board of Supervisors
By:
Dated:
21
EXHIBIT "A"
EMERGENCY RESPONSE AREAS OF SAN LUIS OBISPO COUNTY
ZONE DESCRIPTIONS: .
NORTH COAST ZONE - (CAMBRIA)
Generally described as that area of San Luis Obispo County that has as the west boundary, the
Pacific Ocean from the Monterey County line south to Villa Creek road,with the west boundary
running along the ridge of the Santa Lucia Mountains and the north boundary along the
Monterey County Line and south of Villa Creek Road.
NORTH ZONE- (PASO ROBLES, ATASCADERO, AND CALIFORNIA VALLEY)
Generally described as that area of San Luis Obispo County delineated by Monterey County on
the North, Kern County on the east, and the ridge line of the Santa Lucia Mountains from
Monterey County to Kern County lines.
CENTRAL ZONE - (CAYUCOS, MORRO BAY, SAN LUIS OBISPO, AND AVILA)
Generally described as that area of San Luis Obispo County that is delineated by the Pacific
Ocean on the west, Villa Creek road at the north, the Santa Lucia Mountains on the east, and an
imaginary line that runs from High Mountain Look Out to the Pacific Ocean between Avila and
Shell Beach.
SOUTH ZONE - (FIVE CITIES AND NIPOMO MESA) .
Generally described as that area of San Luis Obispo County that is delineated by the Pacific
Ocean on the west from Shell Beach to the Santa Barbara County line; on the east the Santa
Lucia Mountains from High Mountain Look Out to the.Kern County line, on the South by the
County line of Santa Barbara.
The following more specific descriptions are based on San Luis Obispo County Mutual Aid and
911 Grid/Map System-
NORTH COAST ZONE
ystem:NORTHCOASTZONE
MAP PAGES:2,3,4,24,25,26,27,29,30,59,6I,62,65,91 &94
INCLUDING PORTIONS OF TRE FOLLOWING:
MAP PAGE NUMBERS:
28 EXCLUDE GRIDS: D-1,E-1,E-2,E-3,E-4,E-5
33 INCLUDE GRIDS: A-2,A-3,A-4,A-5,B-3,B-4,B-5,C-5
60 EXCLUDE GRIDS: E-1
63 INCLUDE GRIDS: A-3,A-4,A-5,B-2,B-3,B4,B-5,C-4,C-5,D-5
5 INCLUDE GRIDS: A=2,A-3,A4,A-5
92 EXCLUDE GRIDS: B-5,C-;,C-5,D-3,D-4,D-5,E-2,E-3,E-4,E-5
NORTH ZONE-
FROM THE BELOW NOTED MAP PAGE NUMBERS EAST TO THE KERN COUNTY LINE.
MAP PAGE NUMBER:
5 EXCLUDE GRIDS: A-2,A-3,A-4,A-5
28 INCLUDE GRIDS: D-1,E-1,E-2,E-3,E-4,E-5
33 EXCLUDE GRIDS: A-2,A-3,A-4,A-S,B-3,B-4,B-S,C-5
60 INCLUDE GRIDS: E-1
63 EXCLUDE GRIDS: A-3,A4,A-5,B-3,B-4,B-5
94 EXCLUDE GRIDS: E-1
95 INCLUDE GRIDS: A-1,B-1,C-1,C72,D-1,D-2;D-3,E-1,E-2,E-3,E-4
98 INCLUDE GRIDS: C-1,D-1,D-2,E-1,E-2
100 EXCLUDE GRIDS: A-5
101 EXCLUDE GRIDS: A-4,A-S,B-5
124 EXCLUDE GRIDS: A-I,A-2,A-3,A-4,A-5,B-1,B-2,B-3,B-4,B-S,C-S,D-5,E-5
125 EXCLUDE GRIDS. A-2,A73,A-4,A-5,B-3,Bim,B-S,Com,C-5,D-5
127 INCLUDE GRIDS: E`-1,E-2
130 EXCLUDE GRIDS: A-S,B-5
159 INCLUDE GRIDS: C-1,D-I,D-2,E-1,E-2,E-3,E-4
162 EXCLUDE GRIDS` A=3,A4 A-5,B4,8-5
195 INCLUDE GRIDS: E-1
198 INCLUDE GRIDS: A-1,B-1,B-2,C-1, G2,D-1,D-2,E-1,E-2
199 INCLUDE GRIDS: A-1,A-2,B-1,B-2,C-1.C12,D-1,D-2,E-1,E-2
202 INCLUDE GRIDS: A-1,A-2,B-1,B-2,C-1,C-2,D-1,D-2,E-1,E-2
203 EXCLUDE GRIDS- A-3,A-4,A-5,B-4,B-5,C-5
208 INCLUDE GRIDS: Awl,B-1,C-1,C-2,D-1,D-2,E-1,E-2
209 EXCLUDE GRIDS: A-3,A-4,A-5,B-4,B-5,C-4,C-5,D-S,E-5
212 EXCLUDE GRIDS: A-5
242 EXCLUDE GRIDS: A-3,A-4,A-5,B-3,B-4,B-S,C-4,C-5,D-5,E-5
244 INCLUDE GRIDS: D-1,E-1
246 EXCLUDE GRIDS: A-3,A-4,A-S,B-3,B-4,B-S,C-4,C-5,D-5
263 INCLUDE GRIDS: B-1,C-1,C-2,D-1,D-2,E-1,E-2,E=3
264 EXCLUDE GRIDS: A-4,A-5,B-4,B-5,C-S,D-5
268 INCLUDE GRIDS: A-1,B-1,C-1,D-1,E-1,E-2
CENTRAL ZONE
MAP PAGES: 93,96,97, 120, 121, 122, 123, 126, 151, 152, 155, 156, 153, 154, 157, 161, 186, 187, 190, 191, 194,
183, 159, 192, 193,224,&225
INCLUDING PORTIONS OF THE FOLLOWING:
MAP PAGE NUMBERS:
92 INCLUDE GRIDS: B-5,C-4,C-5,D-3,D-4,D-5,E72,E-3,E4,E-5
94 EXCLUDE GRIDS: E-1
95 EXCLUDE GRIDS: A-1,B-1,C-1,C-2,D-1,D-2,D-3,E-1,E-2,E-3,E4
100 EXCLUDE GRIDS: C-1,D-1,D-2,E-1,E-2
9S INCLUDE GRIDS: A-5
101 INCLUDE GRIDS: A4,A75,B-5
125 INCLUDE GRIDS: A-2,A73,A-4,A-5,B-3,B-4,C-4,C-5,D-5
127 EXCLUDE GRIDS: E-1,E-2
130 INCLUDE GRIDS: A-5,B-5
159 EXCLUDE GRIDS: C-1,D-1,D-2,D-3,E-1,E-2,E=3,E-4,E-5
162 INCLUDE GRIDS: A-3,A-4,A-5,B-4,B-5
195 INCLUDE GRIDS: A-1,A-2,A-3,A-4,A-5,13-1,13-2
196 INCLUDE GRIDS: A-5,B-5,C-5,DS,E-2,E-3,E-4,E-5
226 INCLUDE GRIDS; A-1
SOUTH ZONE
MAP PAGES: 197,200,201,204,205,227,228,23 1,232,235,236,239,240,229,230,233,234,237,238,241,250,
251,252,_53,256,257,254,255,258,259,260,261,262,&267
INCLUDING PORTIONS OF THE FOLLOWING:
MAP PAGE NUMBERS:
195 INCLUDE GRIDS: E-1,A-1,A-2,A-3,A-4,A-5,B-1,B-2,
196 EXCLUDE GRIDS: A-S,B-5,C-5,D-5,E-2,E-3,E-4,E-5
2'216 EXCLUDE GRIDS: A-1
198 EXCLUDE GRIDS: A-1,B-1,B-2,C-1,C-2,D-1 D-2,E 1,E-2
199 EXCLUDE GRIDS: A-1,A-2,B-1,B-2,C-1,C-2,D-1,D-2,E-1,E-2
202 EXCLUDE GRIDS: A-I,A-2,.B-1,.B-2,C-1,C-2,D-I,D-2,E-1,E-2
203 INCLUDE GRIDS: A-3,A-4,A-5,B-4,B-5,C-5
'208 EXCLUDE GRIDS: A-I,B-1,C-1,C-2,D-1,D-2,E-1,E-2
209 INCLUDE GRIDS: A-3,A-4,A-5,B-4,B-5,C-4,C-5,D-5,E-5
212 INCLUDE GRIDS: A-5
242 INCLUDE GRIDS. A-3,A-4,A-5,B-3,B-4,B-5,C-4,C-5;D-5,E-5
244 EXCLUDE GRIDS: D-1,E-1
246 INCLUDE GRIDS: A=3,A-4,A-5,B-3,B=4,B-5,C-4, C-5,D-5
263 -EXCLUDE GRIDS: B-1;C-1,C-2,D-1,D-2,E-1,E-2,E-3
264 INCLUDE GRIDS: A-4,A-S,B-4;B-5,C-5,D-5
268 EXCLUDE GRIDS: A-1,9-1,C-1,D-1,E-1,E-2
EXHIBIT "B"
Deployment Plan
The general goal of the Deployment Plans is to provide an Advanced Life Support(ALS)Unit,either by
Contractor or by an ALS fire service agency,to at least 90%of all potentially life threatening emergency
ambulance requests originating within each Emergency Response Area with a maximum response time
of 10 minutes in areas designated urban, and with a maximum.response time of 30 minutes in areas
designated as rural, and with a maximum response time of 60 in areas designated as remote.
The terms urban, rural, and remote are defined by the California State Emergency Medical Services
Authority as follows:
Urban: All census places with a population of 2,500 to 500,000 and a population density of 100 to 999
persons per square mile; or census tracts and enumeration districts with census tracts which have a
population density of 100 to 999 persons per square mile.
Rural: All census places with a population of less than 2,500 and population density of 10 to 99 persons
per square mile; or census tracts or enumeration districts without census tracts which have a population
density of 10 to 99 persons per square mile.
Remote: Census tracts or enumeration districts without census tracts which have a population density of
5 to 9 persons per square mile.
If the State EMS Authority's definition.of urban,rural, and remote are accepted locally, the cities and
unincorporated areas of San Luis Obispo County would be rated as follows based on California State
Department of Finance and San Luis Obispo County Planning.Department figures:
Urban Areas Rural Areas Remote Areas
City of Arroyo Grande Adelaida' California Valley/
City of Atascadero Avila Beach Simmler
City of Grover City Creston Cholame
City of Morro Bay Garden Farms La Pana
City of Paso Robles San Simeon Pozo
City of Pismo Beach Whitley Gardens * Oak Shores
City of San Luis Obispo Santa Margarita * Shandon
Cambria San Miguel * Heritage Ranch
Cal Poly
Cayucos
Baywood Park/Los Osos
Nipomo
Oceano
Templeton
Country Club(SLO)
* -Shandon, Heritage Ranch and Oak Shores would normally be in the Waal category but are moved to
the remote category due to their size,limited number of EMS responses and location within the county.
SPECIFIC RESOURCE REOUIREMENTS
1. Central Zone .3.3 ambulance units per day
2 public transport units for back-up/over-load response(SLO City,.
Morro Bay)
Current station locations acceptable-(Morro Bay and San Luis Obispo)
2. North Zone 3 ambulance units per day (half time unit allowed to float at Twin Cities
Community.Hospital .
Move-up capability from central zone .
Current station locations acceptable(Paso Robles and Atascadero)
3. South Zone 3 ambulance units per day
Current Station Locations Acceptable(Arroyo Grande and Nipomo)
Contractor shall at all times maintain andoperate one (1) four wheel drive
ambulance unit. This special requirement shall not increase the coverage
requirement setforth above for the South Zone as 3 ambulance units per day.
e=\apoc\conx=t=hfl)-n--Ia
NORTHERN AND CENTRAL ZONES
Northern
Atascadero 583,250.00
Paso Robles $641800.00
San Miguel $3,300.00
San Luis Obispo County $45,900.00
Templeton $6,750.00
Central
Avila Beach $2,850.00
Cayucos $4,200.00
Morro Bay $64,800.00
San Luis Obispo City $129,600.00
San Luis Obispo County $23,400.00
South Bay $50,850.00
Total: $479,700.60
EXHIBIT C
t
EXHIBIT "D"
SAN LUIS ANIBULANCE SERVICE,INC. -SERVICE RATES
Service Rate f$1
ALS Transport $638.00
Miles (per mile) $17.35
Oxygen $67.00
Disposables/Supplies $16.75
Stand-By(per hour) $134.20
ems\apoc\conv=\exhit-c.s la
l
EXHIBIT "E"
PERFORMANCE BOND
KNOW ALL MEN BY THESE PRESENTS: That
WHEREAS, the Board of Supervisors of San Luis.Obispo County has awarded to San
Luis Ambulance Service, Inc. (hereafter designated as"Principal'), a contract for the provisions
of ambulance services to specified areas of the County of San Luis Obispo; and
WHEREAS, said Principal is required under the terms of said contract to furnish a bond
for the faithful performance of said contract;
NOW, THEREFORE, we,the Principal and
as Surety,are held and firmly bound unto the County of San
Luis Obispo (hereafter"County"); in the penal sum of Five Hundred Thousand Dollars
($500,000.00), lawful money of the United States, for the payment of which sum well and truly
to be made, we bind ourselves, our heirs, executors, administrators and successors;jointly and
severally,firmly by these presents..
The condition of this obligation is such that if the above bound Principal,his or its heirs,
executors,administrators, successors or assigns, shall in all things stand to and abide by, and well
and'truly keep and perform the covenants, conditions and agreements in the said contract and any
alteration thereof made as therein provided, on his or their part,to be kept and performed at the
time and in the manner therein specified,and in all respects according to their true intent and
mean�ng, and shall indemnify and.save harmless County, its officers,agents, and employees,as
therein stipulated,then this obligation shall become null and void;otherwise it shall be and
remain in full force,virtue and effect.
The said Surety, for value received, hereby stipulates and agrees that no change,
extension of time, alteration or addition to the terms of the contract or to the work to be
I
performed thereunder or the specifications accompanying the same shall in any wise affectits
obligations on this bond, and it does hereby waive notice of any such change, extension of time,
alteration, or additions to the terms of the contract or to the work or to the specifications.
In the event suit is brought upon this bond by County and judgment is recovered, Surety
shall pay all costs incurred by County in such suit, including a reasonable attorney's fees to be
fixed by the court.
Death of the Principal shall not relieve Surety of its obligations hereunder.
IT WITNESS WIEREOF, one identical counterpart of this instrument,which shall for
all purposes be deemed an original thereof,has been duly executed by Principal and Surety above
named on the day of
(Seal).
(Seal)
(Seal)
Principal -
(Seal)
- (Seal)
--- - (Seal)
(Seal)
Surety
-2- -
I
Address
NOTE:
Signatures of those executing for Surety must be properly acknowledged..
RLS/SLAS-ezhibite.wpd
EMS Membership, SAFD I The City of Santa Ana Page 1 of 2
117n
home site map thingstodo
Santa Ana Fire Department
EmAinsat rdem&nhip
Santa Ana Fire Department
Presents Low Cost Emergency Medical Care
For just$36 per year or$6 per water bill, you can become a member of the Emergency Medical Services
(EMS)Membership Program. This program includes basic emergency service, and medical transportation by
the Santa Ana Fire Department.
The charge for a single EMS response range from$82.30 to over$700, depending on the level of service
provided.As an alternative to paying these direct fees, all Santa Ana residents have the opportunity to join the
EMS Membership Program. Membership provides unlimited use of the emergency medical system for you and
all permanent members of your household.As a member,you will not be assessed any direct fees for
emergency medical services.
• Services Provided
• 24-hour Basic or Paramedic-level service depending on your medical need.
• Emergency ambulance transportation provided by the Santa Ana Fire Department to local hospitals.
• If needed, emergency life-saving instructions over the phone while the Santa Ana Fire Department is
responding.
Some Questions &Answers
Q: Who is eligible to join the Membership Program?
A:Any resident within Santa Ana may join.
Q: What does the$36 membership fee cover?
A: The membership fee covers all emergency medical services provided by the Santa Ana Fire Department,
within the area normally serviced by the Fire Department.
Q: Who is covered by the membership fee?
A:All permanent residents of a member's household.
Q:Are visitors of residential members covered?
A:No. Only permanent residents of a member's household.
Q.If i decide not to join the Membership Program, what are the charges for E.M.S. Services?
A:Anywhere from$82.30 to over$700 depending upon the service level provided.
Q.If I move out of the city after paying the annual membership fee, will I be entitled to a refund?
A:No. There will be no refunds.
Q: Will my membership cover routine ambulance such as trips from hospital to home or rest home to a
hospital?
A:No. E.M.S. is for emergency use only.
Q: MY the Santa Ana Fire Department still respond if 1 do not become a member?
A: Yes. The Fire Department will respond to any call for help.
http://www.santa-ana.org/departments/fire/support_services/ems_membership.htm 4/21/03
EMS Membership, SAFD I The City of Santa Ana Page 2 of 2
Q: ill I be responsible for any of the charges if l become a member?
A:No. If you become a member of this low cost emergency service, no payment will be required of you,
however,your insurance, Medicare or Medi-Cal will be billed. If you are not a member, the usual fees for
services rendered by the Santa Ana Fire Department will be billed to the person receiving the services.
Under no circumstances will the delivery and application of available emergency medical services and
ambulance transportation will be delayed or refused based upon a person's membership or non-membership
in the E.M.S.program or his/her ability or non-ability to pay.
(FOR PROGRAM INFORMATION, PLEASE CALL THE FINANCE DEPARTMENT AT(714) 647-5430 OR
THE WATER DEPARTMENT TO ADD TO YOUR UTILITY BiLL.AT(714) 647-5454.
2/7/01
introduction I Communication I Hiring Process
Emergency Medical Services-Membership Program-(en Espanol) I Training
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Questions or comments?Contact Webmaster
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http://www.santa-ana.org/departrnents/fire/support_services/ems_membership.htm 4/21/03
. Anaheim Fire Department Paramedic Membership Program Pagel of 3
} � rP
37 i
Anaheim Fire Department Paramedic Membership Program
As the costs of medical care rises, it is important to make sure your family is covered in
the event of an emergency. The City of Anaheim Fire Department has a program that is
designed to help you during such emergency situations.
The Paramedic Membership Program is an official program of the City of Anaheim Fire
Department,which offsets the cost of emergency medical responses. Without the
Paramedic Membership Program, one emergency call can cost you hundreds of dollars.
For less than a dime a day, the Paramedic Membership Program guarantees that you
will pay NO out-of-pocket expenses for emergency medical services provided by the
Anaheim Fire Department. Even if you have health insurance, one emergency bill could
still cost you hundreds of dollars. This program will also cover the uninsured portion of
your emergency medical service bill.
If you're not part of the Paramedic Membership Program, you could pay at let$150
per person, for each emergency medical response. However, members in the
are not charged for responses to 91.1 emergency medical calls. It's also important to
note that the Paramedic Membership Program does not cover ambulance services.
This is important because if you were to require a 911 emergency response,and you
member of the Paramedic Membership Program you.will be paying aminimum
of$1 or medical services in addition to the cost of ambulance service.
In the past, all residents who received a utility bill were automatically included in the
paramedic Membership program, unless a resident requested not to participate.
�r However, we have changed the way we maintain memberships. Now you have the
!r' option of participating in the Paramedic Membership Program. That means you have to
notify us in order to reestablish your membership.
Your monthly Paramedic Membership Program fee of$3 will be billed on your utility bill
for a total of$36 per year.YAu and those residing wyou are covered aa)auhGm=
the City of Anaheim 2 365 da s- - _ ith. If you do not receive a utility bill
and would like aeTails on billing options or have questions about the Paramedic
Membership Program, please all us at(714)765-4060.
Frequently Asked Questions
http://www.anaheim.net/depts_servc/fire/ops/Para_mem/medicfaq.html 2/24/03
Anaheim Fire Department Paramedic Membership Program Page 2 of 3
I
1. WHY IS THE PROGRAM BEING CHANGED FROM BEING AUTOMATICALLY
INCLUDED ON MY UTILITY BILL?We have been directed to give residents and
business owners a choice in whether they wish to continue their participation in our
Paramedic Membership Program.
2. DOES MY PARAMEDIC MEMBERSHIP INCLUDE AMBULANCE COSTS?
No. The City contracts with a private ambulance service, so you will receive a separate
bill from CARE Ambulance Service, or another private ambulance company if you
require ambulance transportation.
3. ARENT MY TAXES PAYING FOR THIS SERVICE?
After the passage of Proposition 13 in 1974, cities experienced a significant drop in
revenue, which forced us to come up with alternate methods of revenue.The cost to
provide emergency medical services is expensive. To continue providing outstanding
emergency medical services, there are costs associated with lifesaving equipment and
training.The revenue from this program helps offset some of these costs so that we can
include a paramedic unit in each neighborhood.
4. WHO IS COVERED BY MY RESIDENTIAL MEMBERSHIP?
All those residing at your address are covered anywhere in the city, 24 hours a day.
Those visiting your home are also covered.
5. ARE MY CUSTOMERS COVERED BY MY BUSINESS MEMBERSHIP?
The business owner and his/her employees are covered a h r '
An if the re involved in work-related of the time of the .
Custome overe u th tubers of our residential Paramedic
Membership Program.
6. CAN I STILL ENROLL IF I DO NOT RECEIVE A UTILITY BILL?
Yes. All City residents and business owners can make an annual payment of$36.00.
Checks should be made payable to the City of Anaheim. To ensure proper enrollment in
the program, please note on your check that it is for the Paramedic Membership
Program or call (714) 765-4060 for more details.
7. WHAT IF I CANT AFFORD THE$36.00 A YEAR?
An exemption program is available for those who earn less than $15,000 a year.To
request an exemption application, please call (714)765-4060. Once we process your
application and verify your income,we will exempt you from paying the annual fee. It
should be noted that your exemption must be renewed annually.
8. WHY DOES THE PARAMEDIC MEMBERSHIP FEE APPEAR ON MY UTILITY
BILL?
Since July 1985, billing for the Paramedic Membership Program has been included on
the municipal utility bill as directed by the City Council,
9. DOESN'T MY INSURANCE PAY FOR PARAMEDIC SERVICES?
Since each insurance carrier varies, we recommend that you check with your insurance
company to find out what services they will cover.We have found that many insurance
policies do not cover paramedic services, or if they do offer coverage,they do not cover
the full cost.Additionally, many times a deductible per incident must be paid before the
insurance carrier will begin paying associated costs.
http://www.anaheirn.net/depts_servc/fire/ops/para_mem/medicfaq.html 2/24/03
Anaheim Fire Department Paramedic Membership Program Page 3 of 3
`l i.
10. MY CHILD IS IN DAYCARE IN ANAHEIM, BUT I AM NOTA RESIDENT. MAY I
ENROLL IN THE PROGRAM SO MY CHILD IS COVERED?
No. The program is designed to benefit Anaheim residents and business owners.
Students are covered if they attend a government run school (i.e. public school), or if
they are enrolled in our residential Paramedic Membership Program.
11. 1 LIVE OUTSIDE OF ANAHEIM AND HAVE A PARAMEDIC MEMBERSHIP
WITH ANOTHER CITY.AM I COVERED FOR CALLS INTO ANAHEIM?
No.We do not have reciprocity with other cities'programs.
12. 1 LIVE IN.AN UNINCORPORATED AREA OF ANAHEIM AND PAY A GAS OR
ELECTRIC BILL THROUGH THE ANAHEIM PUBLIC UTILITIES DEPARTMENT.AM I
ELIGIBLE FOR THE PROGRAM MEMBERSHIP?
No. Unincorporated areas ate covered by Orange County Fire Authority..(Note:
Anaheim Fire may respond into those areas based on "mutual aid"agreements with
other agencies.)
13. WHAT ARE THE ASSOCIATED COSTS IF PARAMEDICS ARE CALLED AND I
AM NOT A MEMBER?
A minimum of$15Q,00 is charged per person for each 911 ieal emprgeacy call. The
cost increases if advanced life support measures are initiated. There are NO costs if
you belong to the Paramedic Subscription Program; however, you will receive a bill from
a private ambulance compnay for ambulance transportation.
14. ARE SENIOR CARE FACILITIES FOR THE ELDERLY COVERED? (BOARD
AND CARE, CONVALESCENT HOMES)
The program covers patients, who are bedridden, if the senior care facility maintains a
business membership. Patients who are ambulatory are not covered, but may be
eligible for the exemption program. (See#6 and #7)
15. 1 HAVE A BUSINESS ATONE LOCATION THAT USES SEVERAL UTILITY
METERS. DO I HAVE TO PAY FOR MORE THAN ONE MEMBERSHIP?
No.As long as only one business is involved (one business license), we will bill you only
once.We can reference your secondary accounts to the account which shows your
current paramedic program membership status.
If you have additional questions or are ready to sign up for the Paramedic Membership
Program, please call 714-765-4060
Paramedic Prooram Ere Stations Metro Net Dispatch
http://www.anaheim.net/depts_servc/fire/ops/para_mem/medicfaq.html 2/24/03
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Part IX
Department of
Health and Human
Services
\ Centers for Medicare & Medicaid Services
A 1 42 CFR Part 414 -
Medicare Program; Medicare Ambulance
MMA Temporary Rate Increases
Beginning July 1, 2004; Interim Final
Rule
a _ ,
40288 Federal Register/Vol. 69, No. 126/Thursday, July 1, 2004/Rules and Regulations
DEPARTMENT OF HEALTH AND Room 445-6,Hubert H.Humphrey contraindicated by the beneficiary's
HUMAN SERVICES Building,200 Independence Avenue, medical condition;and(2)only
SW.,Washington,DC 20201;or 7500 ambulance service to local facilities be
Centers for Medicare&Medicaid Security Boulevard,Baltimore,MD covered unless necessary services are
Services 21244-1850. not available locally,in which case,
42 CFR Part 414 (Because access to the interior of the transportation to the nearest facility
HHH Building is not readily available to furnishing those services is covered
[CMS-1492-4FC] persons without Federal Government (H.R.Rep.No. 213,89th Cong.,1st Sess.
identification,commenters are 37 and S.Rep.No.404,89th Cong.,1st
RUN 0938-AN24 encouraged to leave their comments in Sess.,Pt..I,43(1965)).The reports
Medicare Program;Medicare the CMS drop slots located in the main indicate that transportation may also be
Ambulance MMA Temporary Rate lobby of the building.A stamp-in clock provided from one hospital to another,
Increases Beginning July Temporary
is available for persons wishing to retain to the beneficiary's home,or to an
a proof of filing by stamping in and extended care facility.
AGENCY:Centers for Medicare& retaining an extra copy of the comments Our regulations relating to ambulance
Medicaid Services(CMS),HHS. being filed.) services are located at 42 CFR Part 410,
ACTION:Interim final rule with comment Comments mailed to the addresses subpart B and 42 CFR Part 414,subpart
period. indicated as appropriate for hand or H.Section 410.10(i)lists ambulance
courier delivery may be delayed and services as one of the covered medical
SUMMARY:This interim final rule received after the comment period. and other health services under
codifies the four payment provisions for FOR FURTHER INFORMATION CONTACT: Medicare Part B.Ambulance services
Medicare covered ambulance services Anne E.Tayloe,(410) 786-4546. are subject to basic conditions and
contained in section 414 of theSUPPLEMENTARY INFORMATION: limitations set forth at§410.12 and to
Medicare Prescription Drug, Submitting Comments:We welcome specific conditions and limitations
Improvement and Modernization Act of included at§410.40.Part 414,subpart
2003(MMA). comments from the go asst all issues H describes how payment is made for
set forth in this rule to assist op n fully ambulance services covered b
DATES:Effective date:These provisions considering issues and developing y
are effective on July 1,2004. policies.You can assist us by Medicare.
Comment date:To be assured referencing the file code CMS-1492-IFC The Medicare program pays for
consideration,comments must be and the specific"issue identifier"that ambulance services for Medicare
received at one of the addressesprecedes the section on which you beneficiaries when other means of
provided below,no later than 5 p.m.on choose to comment. transportation are contraindicated.
August 30,2004. Inspection of Public Comments: Ambulance services(air and ground)are
ADDRESSES:In commenting,please refer Comments received timely will be divided into different levels of service
to file code CMS-1492-IFC.Because of available for public inspection as they based on the medically necessary
staff and resource limitations,we cannot are received,generally beginning treatment provided during transport.
accept comments by facsimile(fax) approximately 8 weeks after publication These services include the levels of
service listed below.
transmission. of a document,at the headquarters of
You may submit comments in one of the Centers for Medicare&Medicaid For Ground:
three ways(no duplicates,please): Services,7500 SecurityBoulevard • Basic Life Support(BLS]
, • Advanced Life Support,Level 1
1.Electronically.You may submit Baltimore,Maryland 21244,Monday (ALS1)
electronic comments to http:// through Friday of each week from 8:30 • Advanced Life Support,Level 2
www.cros.hhs.gov/regulations/ a.m.to 4 p.m.To schedule an (ALS2)
ecomments or to www.regulations.gov appointment to view public comments, • Specialty Care Transport(SCT)
(attachments must be in Microsoft call telephone number:(410) 786-7197. . Paramedic ALS Intercept(PI)
Word,WordPerfect,or Excel;we prefer I.Background For Air:
Microsoft Word). kgrod • Fixed Wing Air Ambulance(FW)
2.By mail.You may mail written [If you choose to comment on issuesRotary Wing Air Ambulance(RW)
comments(one original and two copies) in this section,please include the Historically,payment levels for
to the following address only:Centers caption"Background"at the beginning ambulance services depended,in part,
for Medicare&Medicaid Services, of your comments.] upon the entity that furnished the
Department of Health and Human Legislative Regulatory Hiservices.Before the implementation of
A. gisative aeguatorystory
Services,Attention:CMS-1492-IFC, the ambulance fee schedule on April 1,
P.O.Box 8011,Baltimore,MD 21244- Under section 1861(s)(7)of the Social 2002,providers(hospitals,including
8011. Security Act(the Act),Medicare Part B critical access hospitals,skilled nursing
Please allow sufficient time for mailed (Supplementary Medical Insurance) facilities,and home health agencies)
comments to be received before the covers and pays for ambulance services, were paid on a retrospective reasonable
close of the comment period. to the extent prescribed in regulations, cost basis.Suppliers,which are entities
3.By hand or courier.If you prefer, when the use of other methods of that are independent of any provider,
you may deliver(by hand or courier) transportation would be contraindicated were paid on a reasonable charge basis.
your written comments(one original for the beneficiary.The House Ways and The Balanced Budget Act of 1997
and two copies)before the close of the Means Committee and Senate Finance (BBA)(establishing section 18340)of
comment period to one of the following Committee Reports that accompanied the Act)mandated the development of
addresses.If you intend to deliver your the 1965 legislation creating the Act an ambulance fee schedule through
comments to the Baltimore address, suggest that the Congress intended that: negotiated rulemaking.On February 27,
please call telephone number(410) 786- (1)The ambulance benefit cover 2002,we published a final rule in the
9994 in advance to schedule your transportation services only if other Federal Register(67 FR 9100)that
arrival with one of our staff members: means of transportation are established a fee schedule for the
Federal Register/Vol. 69, No. 126/Thursday, July 1, 2004/Rules and Regulations 40289
payment of ambulance services under 2004,but with different sunset dates. applicable under the ambulance FS,and
the Medicare program,effective for The four provisions are as follows: ambulance services originating in rural
services furnished on or after April 1, 1.A percentage increase in the FS areas are paid based on a rate that is two
2002.The fee schedule replaced the payment rates for ambulance services— percent higher than otherwise would be
retrospective reasonable cost payment 1 percent for urban and 2 percent for applicable under the ambulance FS.
system for providers and the reasonable rural ambulance services.This increase
charge system for suppliers of sunsets on December 31,2006. B.Payment Rate for Mileage Greater
ambulance services.Additionally,the 2.A 25 percent increase for the Than 50 Miles
final rule—implemented a statutory mileage rate for miles 51 and greater Section 414.610 is amended by
requirement that ambulance suppliers (both urban and rural).This increase adding a new paragraph(c)(7)to specify
accept Medicare assignment;codified sunsets on December 31,2008. that,for services furnished during the
the establishment of new Health Care 3.A Regional FS that provides a floor period July 1,2004 through December
Common Procedure Coding System amount for the ground ambulance base 31,2008,each loaded ambulance mile
(HCPCS)codes to be reported on claims rate.The floor amount is determined by greater than 50(that is,miles 51 and
for ambulance services;established establishing nine FSs based on each of greater)for ambulance transports
increased mileage payment under the the nine census divisions using the originating in either urban areas or in
fee schedule for ambulance services same methodology as was used to rural areas are paid based on a rate that
furnished in rural areas based on the establish the national FS.This increase is 25 percent higher than otherwise
location of the beneficiary at the time sunsets on December 31,2009. would be applicable under the
the beneficiary is placed on board the 4.An increase in the payment for the ambulance FS.
ambulance;revised the certification base rate where the ambulance transport
requirements for coverage of originates in a rural area determined by C.Regional Ambulance Fee Schedule
nonemergency ambulance services;and the Secretary to be in the lowest 25th A new section 414.617 is added to
provided for a 5=year transition period percentile of all rural populations specify that for services furnished
during which program payment for arrayed by population density.Rural during the period July 1,2004 through
Medicare covered ambulance services areas include Goldsmith areas(a type of December 31,2009,the ground
would be based upon a blended rate rural census tract).To determine these ambulance base rate is subject to a floor
comprised of a fee schedule portion and rural areas,first,all areas(rural counties amount,which is determined by
a reasonable cost(providers)or plus Goldsmith areas)are arrayed in establishing nine fee schedules based on
reasonable charge(suppliers)portion. ascending order by population density. each of the nine census divisions,and
We are now in the third year of that Then,all of these rural areas are divided using the same methodology as was
transition to full payment based solely into quartiles by population.The rural used to establish the national FS.If the
on the fee schedule amount. areas that comprise the lowest quartile regional FS methodology for a given
of population(that is,the lowest 25 census division results in an amount
B. Transitional Assistance for Rural percent of rural population)comprise that is lower than the national ground
Mileage 18 Through 50—Section 221 of the areas eligible for this bonus base rate,then it is not used,and the
the Medicare,Medicaid and SCHrP payment.Approximately half of all rural national FS amount applies for all
Benefits Improvement and Protection areas(rural counties plus Goldsmith providers and suppliers in the census
Act of 2000(BIPA) areas)are required to include 25 percent division.If the regional fee schedule
Section 221 of the Benefits of the rural population when rural areas methodology for a given census division
Improvement and Protection Act of are arrayed by population density.The results in an amount that is greater than
bonus amount is based on the the national ground base rate,then the
2000(BIPA)provided a temporary
bonus mileage payment through Secretary's estimate of the ratio of the FS portion of the base rate for that
December 31,2003 for miles 18 through average cost per trip for the rural areas census division is equal to a blend of
50 for ambulance transports originating in the lowest quartile compared to the the national rate and the regional rate in
in a rural area.This bonus amount average cost per trip for the rural areas accordance with the following schedule:
could not be less than one-half of the
in the highest quartile.m making this
rural bonus paid under the ambulance estimate,the Secretary may use data Time period Regional percent National
fee schedule for miles 1 through 17. provided by the General Accounting percent percent
This provision was implemented b Office(GAO).This provision sunsets on 7/1/04-12131/04 ........ 80 20
p p y December 31,2009.
§414.610(c)of the ambulance fee CY 2005.................... 60 40
schedule final rule. IL Provisions of the Interim Final Rule CY 2006.................... 40 60
C.Medicare Prescription Drug, [If you choose to comment on issues CY 2007-0Y then ... 20 80
P g CY 2010 and there-
Improvement and Modernization Act of in this section,please include the after ....................... 0 100
2003(MMA) caption"Provisions of the Interim Final
Rule"at the beginning of your D.Super-Rural Bonus
Section 414 of the Medicare comments.]
Prescription Drug,Improvement and Section 414.610(c)(5)is amended to
Modernization Act of 2003(MMA) A.Percentage Increase in the Payments specify that,for services furnished
contains four provisions affecting for Rural and Urban Ambulance during the period July 1,2004 through
payment for Medicare-covered Services December 31,2009,the payment
ambulance services.All four affect only Section 414.610 is amended by amount for the ground ambulance base
the fee schedule(FS)portion of the revising paragraph(c)(1)to specify that, rate is increased where the ambulance
program's payment,and they affect only for services furnished during the period transport originates in a rural area
ground ambulance services.They are all July 1,2004 through December 31,2006, included in those areas comprising the
cumulative;that is,they are percentage ambulance services originating in urban lowest 25th percentile of all rural
increases applied in concert with one areas are paid based on a rate that is one populations arrayed by population
another.They are all effective July 1, percent higher than otherwise would be density.Rural areas include Goldsmith
40290 Federal Register/Vol. 69, No. 126/Thursday, July 1, 2004/Rules and Regulations
areas(a type of rural census tract). the Physician Certification of each level of ground ambulance
Approximately half of all rural areas Requirements for Coverage of services needed to satisfy the regression
(rural counties plus Goldsmith areas) Nonemergency Ambulance Services")— formula.The proxy that the GAO used
are required to include 25 percent of the Final Rule with Comment Period, for the total number of ambulance trips
rural population arrayed in order of published February 27,2002 (67 FR was the number of Medicare ambulance
population density.The amount of this 9100).We then determined a regional trips doubled.We then took the
increase is based on the Secretary's conversion factor(CF)by using the 2001 predicted average cost per trip in those
estimate of the ratio of the average cost claims data from the states in each rural areas in the lowest quartile of rural
per trip for the rural areas comprised of Census Division.Then we divided the population arrayed by population
the lowest quartile of population regional CF by the national CF for 2001 density and compared that cost to the
arrayed by density compared to the claims data.Where this result was less predicted average cost per trip in the
average cost per trip for the rural areas than 1.0,the value of 1.0 was used. rural areas in the highest quartile of
comprised of the highest quartile Then we multiplied this number by 80 rural population arrayed by population
arrayed by density.In making this percent,which is the statutory phase-in density.The result was that the average
estimate,the Secretary may use data percentage of the regional FS for 2004, cost per trip in the lowest quartile was
provided by the GAO.We have and added 0.2 (20 percent of 1.0)to that 22.6 percent higher than the average
determined that the amount of this amount.In this way we created an index cost per trip in the highest quartile.
increase is equal to 22.6 percent. that reflects a blended FS amount of 80 IV.Waiver of Proposed Rulemaking
III.Methodology percent regional and 20 percent We ordinarily publish aproposed rule
gY national FS.This index was then Y P
[If you choose to comment on issues applied to the FS portion of the blended in the Federal Register and provide a
in this section,please include the payment rate for the period July 1,2004 period for public comment before we
caption"Methodology"at the beginning through December 31,2004.In publish a final rule.We can waive this
of your comments.] subsequent years,the blending procedure,however,if we find good
A.Percentage Increase in the Payments amount agnationale between the
nd the regi ns
al FS amount will procedure notice
e impracticable,
for Rural and Urban Ambulance change as described in the chart,shown unnecessary,or contrary to the public
Services in section II.C.,above. interest,and we incorporate a statement
This provision is self-implementing. DSuper-Rural Bonus of this finding and its reasons in the rule
D.A plain reading of the statute requires P issued.We find it unnecessary to
a merely ministerial application of the The statute states that in establishing undertake notice and comment
mandated increase in rates,and there is the super-rural bonus,CMS will rulemaking in this instance because the
no authority for any discretionary action estimate the average cost per trip in the statute specifies that these provisions
by the Secretary. lowest quartile(25 percentile)of rural may be implemented on the bass of an
Payment Rate for Mileage Greater Population arrayed by population interim final rule or program
B.Paym
Than m Miles density as compared to the estimate of instruction,in recognition of the fact
the average cost per trip in the highest that the statutorily required
This provision is self-implementing. quartile of rural population arrayed by implementation date could not be met
A plain reading of the statute requires population density.In order to otherwise.Pursuant to this authority,
a merely ministerial application of the implement this provision promptly, we have issued program instructions to
mandated increase in rates,and there is data may be used from the Comptroller our contractors implementing these
no authority for any discretionary action General(GAO)of the U.S.We obtained provisions with an effective date of July
by the Secretary. the same data as the data that were used 1,2004,as specified by the statute.The
C.Regional Fee Schedule in the GAO's September 2003 Report purpose of this IFC s to provide a
titled"Ambulance Services:Medicare vehicle for public comment and to
The statute requires that the same Payments Can Be Better Targeted to conform the Code of Federal
methodology be used to determine each Trips in Less Densely Populated Rural Regulations(CFR)to the statutory
of the regional fee schedules as was Areas"(GAO report number GAO-03– language.Chapter 8 of the Contract with
used to determine the national FS.We 686)and used the same general America Advancement Act of 1996
applied this methodology to Medicare methodology in a regression analysis as (CWAAA)generally requires an agency
claims data from calendar year 2001.We that used in that report.We considered to submit a rule to Congress 60 days
used 2001 data because they were the only the full cost providers that were before it is to be effective.The CWAAA,
most recent complete data for a year in included in the data set,just as the GAO however,contains an exception where
which Medicare payments were based had done.The regression analysis the rule includes a waiver based on
solely on the reasonable charge/ correlated the providers'ambulance good cause,as here.For this reason,and
reasonable cost payment methodologies costs to the number of trips,the square because we have already implemented
and not blended with portions of the of the number of trips,and the these provisions of the MMA under the
national ambulance fee schedule percentage of trips that were advanced authority cited,we have concluded that
implemented on April 1,2002.We life support(ALS)as opposed to those the requirement for a 60-day delay in
needed to use these former payment that were at the basic fife support(BLS) effective date for congressional review
amounts(that is,payments exclusive of level of care.The result of this of major rules does not apply in this
the national FS amounts)to apply the regression was a formula that predicted case.
methodology used for determining the the average cost per trip based on the V.Collection of Information
national FS,which had originally used variables just described.We then used
claims data from 1998.For a full the Medicare claims data from calendar Requirements
description of this methodology,see the year 2002 from every ambulance This document does not impose
Federal Register("Medicare Program; supplier and provider that furnished information collection and record
Fee Schedule for Payment of ambulance services in any rural area. keeping requirements.Consequently,it
Ambulance Services and Revisions to These claims data showed the number need not be reviewed by the Office of
Federal Register/Vol. 69, No. 126/Thursday, July 1, 2004/Rules and Regulations 40291
Management and Budget under the BREAKOUT OF 2004 REGIONAL FS IM- the provisions of section 604 of the
authority of the Paperwork Reduction PACT ON GROUND BASE RATES BY RFA.For purposes of section 1102(b)of
Act of 1995. CENSUS DIVISION the Act,we define a small rural hospital
as a hospital that is located outside of
VL Regulatory Impact Analysis Regional fac- a Metropolitan Statistical Area and has
[If you choose to comment on issues Census division for percent- fewer than 100 beds.This rule will
in this section,please include the creases impact small rural hospitals to the
caption"Regulatory Impact Analysis"at extent that they furnish Medicare
the beginning of your comments.] 1. New England(CT,ME,MA, covered ambulance services.As noted
NH,RI,VT) ......................... 23,3 above,ambulance FS payments are
A.Overall Impact 2. Middle Atlantic(NJ,NY, increased by 2 percent for all rural trips,
PA) ...................................... 4.7 and there is a 22.6 percent increase in
We have examined the impacts of this 3. East North Central(IN, IL, the base rate payments for ambulance
rule as required by Executive Order MI,OH,WI) ......................... 0 transports in the least populated rural
12866(September 1993,Regulatory 4.West North Central(IA,KS, areas in the country.
Planning and Review),the Regulatory MN, MO,NE,ND,SD)........ 0 Section 202 of the Unfunded
Flexibility Act(RFA)(September 16, 5.South Atlantic(DE,DC,FL, Mandates Reform Act of 1995 also
p GA,MD,NC,SC,VA,WV) 0
1980,Pub.L.96-354),section 1102(b)of 6.East South Central(AL, requires that agencies assess anticipated
the Social Security Act,the Unfunded KY,MS,TN)........................ 0 costs and benefits before issuing any
Mandates Reform Act of 1995(Pub.L. 7.West South Central(AR, rule that may result in expenditure in
104-1),and Executive Order 13132. LA,OK,TX) ........................ 10.2 any 1 year by State,local,or tribal
8. Mountain(AZ,CO, ID,NM, governments,in the aggregate,or by the
Executive Order 12866(as amended MT,UT,NV,WY) ................ 9.9 private sector,of$110 million.This rule
by Executive Order 15258,which 9.Pacific(AK,CA,HI,OR, does not have any unfunded mandates.
merely reassigns responsibility of WA) ..................................... 38.6 Executive Order 13132 establishes
duties)directs agencies to assess all The Regulatory Flexibility Act A certain requirements that an agency
costs and benefits of available regulatory Bu rY tY (RFA) must meet when it issues a proposed
alternatives and,if regulation is requires agencies to analyze options for rule(and subsequent final rule)that
necessary,to select regulatory regulatory relief of small businesses.For imposes substantial direct requirement
approaches that maximize net benefits purposes of the RFA,small entities costs on State and local governments,
(including potential economic, include small businesses,nonprofit preempts State law,or otherwise has
environmental,public health and safety Most hospitals and anizations,and most otherproviders
not impose any compliancep sle does
on the
effects,distributive impacts,and and suppliers.are small entities,either P y
equity).A regulatory impact analysis governments mentioned.
by nonprofit status or by having
(RIA)must be prepared for major rules revenues of$6 million or less in any 1 B.Anticipated Effects
with economically significant effects year.For purposes of the RFA,most This rule results in increased
($too million or more in any 1 year).We ambulance providers and most spending for all Medicare-covered
have determined that this is a major ambulance suppliers are considered ambulance services furnished to
rule. small businesses.Individuals and States Medicare beneficiaries.Therefore,all
The following impacts reflect the fact are not included in the definition of a entities that furnish these services will
that the effective date of the MMA small entity.This rule will have a benefit from increased program
provisions is July 1,2004 for all significant impact on all ambulance revenues.Entities that furnish these
provisions.The figures are Medicare's providers and suppliers to the extent services in rural areas will particularly
expenditures(that is,exclusive of the that this rule authorizes higher benefit from increased revenue and
Part B coinsurance and deductible payments to anyone furnishing especially those rural entities that
requirements).These impacts also Medicare-covered ambulance services to furnish these services in the least
reflect the fact that the MMA provisions Medicare beneficiaries.There is a one populated areas in the country.Entities
affect only the FS portion of the blended percent increase in payments for all that furnish these services in 26 States
payment during the transition period, urban transports and a two percent will benefit from increased revenue
and,e t during
the he portion n only 60 increase in payments for all rural resulting from the payment floor
ed, nt 0 the total blended s payment(40 transports,as well as a 22.6 percent established based on the regional FS.
p P San increase in payments for the base rate in There will be a commensurate cost to
percent of the payment is from the the least populated rural areas in the the Medicare program of approximately
former reasonable charge/reasonable country.Also,there is a 25 percent $840 million over the total 5-year period
cost methodology). increase in the payments for mileage in during which these provisions will be in
Program Impact: excess of 50 miles,which we anticipate effect.
will occur primarily in rural areas.
Cost Finally,the ambulance entities C.Alternatives Considered
Fiscal year ($millions) furnishing services in 26 States will This rule conforms the Medicare
receive increased payments to their base program regulations to the statutory
2004....................................... 20 rate because of the FS rate floor provisions contained in section 414 of
2005....................................... 200 established by census division. the MMA.These provisions are
2006 ........................................ 220 In addition,section 1102(b)of the Act essentially prescriptive in the statute
2007........................................ 160 requires us to prepare a regulatory and do not allow for discretionary
2008 ........................................ 120 impact analysis if a rule may have a alternatives on the part of the Secretary.
2009 ........................................ 120 significant impact on the operations of In determining the super-rural bonus
a substantial number of small rural amount,we followed the statutory
hospitals.This analysis must conform to guidance of using the data from the
40292 Federal Register/Val. 69, No. 126/Thursday, July 1, 2004/Rules and Regulations
GAO report cited above and followed services furnished during the period during the period July 1,2004 through
the same regression analysis that was July 1,2004 through December 31,2006, December 31,2008,each loaded
used in that report. ambulance services originating in urban ambulance mile greater than 50(that is,
D.Conclusion areas(both base rate and mileage)are miles 51 and greater)for ambulance
paid based on a rate that is one percent transports originating in either urban
Because this rule results in higher higher than otherwise is applicable areas or in rural areas are paid based on
payments to all entities that furnish under this section,and ambulance a rate that is 25 percent higher than
Medicare-covered ambulance services to services originating in rural areas(both otherwise is applicable under this
Medicare beneficiaries,we anticipate base rate and mileage)are paid based on section.
that the primary effect of this rule will a rate that is two percent higher than (3)A new§414.617 is added to read
be to increase revenues for these otherwise is applicable under this as follows:
entities.This rule will not adversely section.The service-level base rate is
affect any of these entities.Those then adjusted by the GAF.Compare this §414.617 Transition from regional to
entities that furnish ambulance services amount to the actual charge.The lesser national ambulance fee schedule.
in rural areas will particularly benefit, of the actual charge or the GAF adjusted
especially for those services furnished base rate amount is added to the lesser For services furnished during the
in the least populated rural areas, of the actual mileage charges or the period July 1,2004 through December
In accordance with the provisions of payment rate per mile,multiplied by the 31,2009,the amount for the ground
Executive Order 12866,this regulation number of miles that the beneficiary ambulance base rate is subject to a floor
was reviewed by the Office of was transported.When applicable,the amount determined by establishing nine
Management and Budget. appropriate RAF is applied to the fee schedules based on each of the nine
ground mileage rate to determine the census divisions using the same
List of Subjects in 42 CFR Part 414 appropriate payment rates.The RVU methodology as used to establish the
Administrative practice and scale for the ambulance fee schedule is national fee schedule.If the regional fee
procedure,Health facilities,Health as follows: schedule methodology for a given
professions,Kidney diseases,Medicare, • * * census division results in an amount
Reporting and record keeping (5)Rural adjustment factor(RAF). (i) that is less than or equal to the national
requirements. For ground ambulance services where ground base rate,then it is not used,and
■For the reasons set forth in the the point of pickup is in a rural area,the the national FS amount applies.If the
preamble,the Centers for Medicare& mileage rate is increased by 50 percent regional fee schedule methodology for a
Medicaid Services amends 42 CFR for each of the first 17 miles and by 25 given census division results in an
chapter IV as set forth below: percent for miles 18 through 50.The amount that is greater than the national
standard mileage rate applies to every ground base rate,then the FS portion of
PART 414—PAYMENT FOR PART B mile over 50 miles.For air ambulance the base rate for that census division is
MEDICAL AND OTHER HEALTH services where the point of pickup is in equal to a blend of the national rate and
SERVICES a rural area,the total payment is the regional rate in accordance with the
increased by 50 percent;that is,the following schedule:
Subpart H—Fee Schedule for rural adjustment factor applies to the
Ambulance Services sum of the base rate and the mileage Time period Regional National
■1.The authority citation for part 414 rate. percent percent
continues to read as follows: (ii)For services furnished during the 7/1/04-12/31104 ........ 80 20
period July 1,2004 through December CY 2.0.0.5.................... 60 40
Authority:Secs.1102,1871,and 1881(b)(1) 31,2009,the payment amount for the CY 2006.................... 40 60
of the Social Security Act(42 U.S.C.1302, ground ambulance base rate is increased CY 2007-CY 2009 ... 20 80
1395hh,and 1395rr(b)(1)). by 22.6 percent where the point of CY 2010 and there-
0 2.Section§414.610 is amended by— ppickup is in a Waal area determined to after....................... 0 100
■A.Revising paragraph(c)(1). be in the lowest 25 percent of rural
■B.Revising paragraph(c)(5). population arrayed by population (Catalog of Federal Domestic assistance
■C.Adding paragraph(c)(7). density.The amount of this increase is Program No.93.774,Medicare—
The revisions and addition read as based on CMS's estimate of the ratio of Supplementary Medical Insurance Program)
follows: the average cost per trip for the rural Dated:May 27,2004.
§414.610 Basis of payment. areas in the lowest quartile of Mark B.McClellan,
population compared to the average cost Administrator,Centers for Medicare&
• * *
per tri for the rural areas in the highest p p Medicaid Services.
(c)' quartile of population.In making this
* * * estimate,CMS may use data provided Approved:)ane 17,2004.
(1)Ground ambulance service levels. by the GAO. Tommy G.Thompson,
The CF is multiplied by the applicable * * * Secretary.
RVUs for each level of service to (7)Payment rate for mileage greater FR Doc.04-15090 Filed 6-30-04;8:45 am)
produce a service-level base rate.For than 50 miles.For services furnished BILLING CODE 412D-M-P
11/14 /95 E.
oJ11041 City of SAT t LUIS 013IS00 ITEM NUMBER:
COUNCIL AGENDA REPORT
FROM: Robert F. Neumann, Fire Chief
SUBJECT: Ambulance Contract Study Session
CAO RECOMMENDATION
By motion, receive a report regarding alternatives for ambulance operations within the City of San
Luis Obispo and direct staff to.further develop Alternatives 3 and 4 and return to City Council with
further information.
REPORT IN BRIEF
For at least seven years now, cities and districts throughout the County have been at odds with the
current ambulance system. Concerns include: lack of local control, standardization of care,
duplication of service, definitions of service levels and a process for change. This county is not
unique in this venture. Currently, cities and counties throughout the state are litigating the issue of
providing pre.hospital care.and ambulance transportation. .It is important to note that San Luis
Obispo is currently served by a very professional and well-run private provider.
The entire pre-hospital care system as we know it, is changing. The future focus will be on trying
to limit costs while still providing safe professional care. An expansion of the role of paramedics,
both public and private, has been on-going for quite some time and is certain to continue in the
future. Some Fire Departments, with little modification of existing personnel, are expanding their
roles in the pre-hospital medical care system.
Local cities and fire districts have been involved in long and drawn-out negotiations with the County
and the private providers defining their role in the pre-hospital system. These discussions have
resulted in the development of a new contract. The following summarizes the proposed contract
and discusses a number of alternatives that are available to the Council.
DISCUSSION
Working cooperatively, the Fire Chiefs, County administrative staff and private providers have
managed to negotiate a tentative agreement. The significant areas are:
s New ambulance zones have been created and the resources that must be provided in those
specific areas have been defined. Ambulance station locations and the number of units
assigned are now finalized.
s Contract language has been developed that meets all the legal requirements for public and
private interests. Issues such'as emergency take-over, dispatch funding, support of the
Critical Incident Stress Team, training, and equipment requirements have been resolved.
• It has been established that fire agencies are an integral component in the system. This is
based upon two separate levels that fire service personnel provide: Emergency Medical
Technicians with defibrillator capability (EMT-D) or Emergency Medical Technician-
Paramedics (EMT-P). We have created a funding mechanism to reimburse these services.
.!11S111j FA1111 city Of n Luis.OBISPO
COUNCIL AGENDA REPORT"
The following chart outlines what various agencies in the central zone, which includes the
area from Avila Beach to the Cuesta ridge north to Cayucos, could hope to expect. It should
be noted that these are very narrowly-defined direct costs and do not reflect all costs
associated with pre-hospital care. Staff does not necessarily agree that this is adequate
funding. It is simply what we have been able to negotiate to date.
The return rates in Chart #1 are based on the following cost figures:
EMT-D Training Costs = $150/Yr. Per Person EMT-D Equipment Costs = $1;500/Yr.
EMT-P Training Costs = $1,500/Yr. Per Person EMT-P Equipment Costs = $3,500/Yr.
EMT-P Incentive = .$4,500/Yr. Per Person
Based on the negotiated rate, the City Fire Department would have a one-time expense of
$3,000 (to equip an existing fire apparatus as a back-up transportation unit) and would
qualify for a return of$107,500 per year.
CENTRAL
ZONE
DEPARTMENT #OF EMT D #OF EMT-P TRAINING EQUIPMENT EMT-P TOTAL
EMPLOYEES/ EMPLOYEES/ COSTS/YR. COSTSIYR. INCENTIVE
PIECES OF PIECES OF
EQUIPMENT EQUIPMENT
Avila Beach 10/1 0 $1,500 $1,500 0 $3,000
Cambria F.D. 0 0 0 0 0 0
Cayuoos F.D. 1111 0 $1,650 $1,500 0 $3,150
Morro Bay 0 7/2 $10,500 $7,000 $31,500 $49,000
San Luis Obispo 0 15/5 $22,500 $17,500 $67,500 $1071500
SLO Co. Avila 16/1 0 $2,400 $1,500 0 $3;900
SLO Co 16/1 0 $2,400 $1,500 0 $3,900
Morro/roto
SLO Co. Airport 16/1 0 $2,400 $1,500 0 $3,900
South Bay 0 6/2 $9.,000 $7,000 $27,000 $43,000
ZONE TOTAL. 6915 28/9 $52,350 $39,000 $126,000 $217,350
ACTION NEEDED
A decision must be made pertaining to pre-hospital we and patient transport. Four alternatives are
presented here for Council's review.
1
City Of Sai i lues OBISPO
COUNCIL AGENDA REPORT
ALTERNATIVE #1
Delete Emergency Medical Service From The Current Fire Department Program.
When the Fire Department was first established, the sole purpose was to combat unwanted foes. Over
the years, the fire service has evolved into a multi-functional organization. As a response to the needs
and expectations of the citizens of San Luis Obispo, emergency medical service became an important
part of our department's mission in the early 70's. We have progressed into providing Advanced Life
Support (AIS) capabilities, more commonly known as "paramedic", from our engine companies. This
alternative would take us back to our original sole purpose, combating unwanted fires. The department
currently responds to approximately 2,400 calls a year,.approximately 70% of which are medical aids.
Pros
The City could realize cost savings, no longer having to provide for training and certification of
paramedics. We would not have to maintain advanced life support equipment and supplies.
The Department would increase its readiness for fire suppression. Engine companies would not be
tied-up at routine medical calls and would be capable of responding to fire emergencies with less
potential for delay.
The Fire Department would have one primary mission. It is easier to accomplish a single goal such as
fire suppression. When you have a multi-functional organization, priorities are often conflicting.
There would be elimination of competition with private enterprise. The current dual-response system o
both private and public agencies would end. Private enterprise would take complete control and
responsibility of all facets of pre-hospital care within the City.
Cons
The potential for loss-of-life would increase due to reduced emergency medical (EMS) response.
Eliminating the current level of care provided by AIS engine companies .would significantly delay
delivery of critical medical treatment to our citizens.
There would be a reduction in the established level of service. The City currently has fire stations
strategically located throughout the community to provide fire protection rapidly and efficiently. Our
current level of service provides ALS within 4-6 minutes throughout the city. There is no higher level
of service available. If we were to reduce or eliminate EMS from our mission, the standard response
time for providing care would be substantially increased, resulting in greater mortality and exacerbation
of injury and illness.
Eliminating this service would be an inefficient use of the department's existing personnel and
equipment. The amount of personnel currently assigned to emergency response is minimal. We have
taken advantage of our successful fire prevention program to reduce the amount of fires. This has
given us time to focus on other areas of emergency response. Emergency medical service has been .
determined to be a high priority based on the fact that the vast majority of 911 calls are medical in
nature. The Fire Department is able to respond to the medical needs of our citizens with the curre"'
level of staffing, and should not reduce the number of personnel due to the potential for disc
ff
!111%N(111111f I cityof ;1 tuis.ogispo -
COUNCIL AGENDA REPORT
ALTERNATIVE #2
Private Provider-Based Transportation With Cost Reimbursement To The Fire Department
(Support The New Contract).
This is the most basic of the cost-recovery proposals. No additional personnel or equipment would be
added to the system.
Pros
The City would be reimbursed approximately $107,500 a year by accepting the contract as currently
negotiated. While it does not bring total cost recovery, it would offset some of,the operating costs.
Other cities throughout the County would be receiving similar treatment. While the proposed contract
is not ideal, there seems to be a general consensus among the private providers, County administrative
staff and the Fire Chiefs that the contract, as developed, would be acceptable.
While the return will not be as much as we would want, the new contract, which we expect to cover a
period of 3-5 years, establishes three important principles which we believe are more important at this
time than just the fiscal impact:
.• Establishes a major role for cities in setting.pre-hospital emergency care standards
• Eliminates a number of deficiencies and results in an improved service delivery system.
• Establishes cost recovery as an integral part of the system.
Cons
It only reimburses a portion of the true costs of the City's involvement in pre-hospital emergency care.
With EMS calls rising to 70% of the emergency-related calls, it could be argued that the cost for
delivering ALS to the citizens of San Luis Obispo is much greater, and total reimbursement should be
the goal. The City would be locked in to $107,500 per year for the life of the contract. A greater
reimbursement amount would require renegotiation, pitting the City Fire Department against other
providers.
It does not resolve duplication of service issues. Both public and private agencies would still continue
to respond to the same incident, needed or not.
ALTERNATIVE #3
Fire Department Based Transportation System.
It would be possible for the Fire Department to operate its own emergency ambulance system. This
would require augmentation to the existing Fire Department staff to provide the best EMS delivery and
transport system possible.
improved program efficiency. This alternative would provide for a fourth 3-person ALS engine
company capable of delivering paramedic level-of-care within four minutes inside the City limits.
Presently we can only staff three engine companies with 3 personnel. Medical studies have shown the Fr`
key to successful resuscitation of cardiac arrest victims is the arrival of ALS care within 4-6 minutes.,
By adding a third person to the fourth engine company, fire suppression efforts would be imprr
i11 city Of s_,,'1 IUIS OBISPO
COUNCIL AGENDA REPORT"'
and staffing levels would be adequate to allow for further annexations and/or growth. Safety would
be enhanced by eliminating the second engine response to ALS calls in the district presently covered
with a 2-person engine company.
Provides the citizens with a paramedic ambulance staffed 24 hours per day. This ambulance could
assist with other Fire Department duties when not involved in patient transport.
The apprentice program funded by this alternative would supply the EMT drivers for the ambulance
service. It would also provide candidates with both EMS and Fire Suppression experience making it
very attractive to persons seeking a fire service career, as well as a hiring pool for future City
firefighters. Apprentice programs can also assist the City with its affirmative action policies. The
City of Huntington Beach has successfully.initiated a similar program.
Anticipated return of$114,700 to the General Fund after paying the costs of providing the service.
(Further discussion/cost analysis to follow.)
Cons
There is a possibility of creating conflict between the City,the County, and the private providers.
Private providers could argue that the loss of income would necessitate higher fees in the
unincorporated area. However, the private provider, based on City participation, would no longer
be required to staff the zone with the same level of resources.
The City would have to agree to respond anywhere in the zone for mutual aid purposes. They
would also have to agree to move out of the zone on limited occasions. The County would need to
agree that the mutual aid was reciprocal, so that in times of system overload, adequate resources
would respond to the City.
The City may incur significant litigation costs to challenges made by the private providers. Current
litigation has ruled in favor of local/public control. A decision filed October 17, 1995, by the 4th
Appellate District of the California Court of Appeals ruled that State law for emergency medical
care does not pre-empt the City's right to provide pre-hospital emergency services (County of San
Bernardino vs. City of San Bernardino).
Discussion/Cost Analysis
The following is a preliminary cost breakdown of how a Fire Department based EMS delivery and
transportation system would look.
Expenses (Annual Basis).
Staffine
Firefighter/Paramedic Position (3.3)* $237,fi00
Apprentice Program 75,0001
Accounting Assistant Position (1/2 Time Billing/Collections Agent) 18,000
Sub-Total '3305600
* In order to staff one position per shift, it is necessary to fund at a factor of 3.3 to
compensate for holiday, vacation time, etc.
14111WRIN City Of t 1 LUIS OBISPO
COUNCIL AGENDA REPORT
Ambulance Supplies F4„inment & Contingenci
Ambulance (5 Yr. Life) $12,000
Fuel and Maintenance 21000
Medical Supplies ** 1,000
Office Equipment/Supplies 2,000
Contingencies (10%) $33,000
Sub-Total 50,000
TOTAL EXPENSES $3809600
** These are direct costs for safety equipment essential for increased Paramedic service. The
Department is currently spending $8,100 on medical equipment and supplies. The required
$1,000 would be in addition to the existing accounts.
The City's current liability insurance carrier has indicated that no increase in insurance premiums
would result from the additional transportation capabilities due to the fact that current practice finds
Firefighters assisting in the ambulance already.
Revenue Source
The department responds to approximately 1,600 emergency medical calls a year. In 1994, there
were 1,100 transports resulting from these calls. Projected transports in 1995 are 1,150 and 1,200
for 1996. (Inter-facility transfers are not included in these numbers) .
The new ambulance rate is expected to be somewhere in the neighborhood of$575 a call, with an
additional revenue source of $60 for the use of oxygen and $15 per transport for infectious disease .
control. The average total, we could expect to bill for a call would be approximately $635. A
realistic collection rate should be about 65-70%.This is based upon the experience of similarly-
sized and socio-economically based communities; Petaluma and Napa. At the collection rate of
65%, a.total of$495,300 could be expected for transports in 1996.
REVENUE (1,200 calls x $635 x Collection Factor of .65) $495,300
PROGRAM COSTS 3809600
LN TO THE [GENERAL FUND $114270
Additional Revenue Possibilities
Public agencies offering ambulance transportation can offer a membership program to residents.
Customers appreciate coverage of all ambulance related "out of pocket" expenses and relief from
dealing with their insurance companies. Public providers benefit from added revenue and very
effective public relations. Based on the experience of agencies throughout the State that have
membership programs, our City could realize between $30,000 and $60,000 of additional revenue in
the first year. Another benefit of far greater value is public relations. Cities and service districts
have found that their residents' awareness and appreciation of emergency-response service greatly
increases. An additional indirect revenue benefit happens when members and non-members alike
tend to utilize the ambulance service more often. Examples of cities with programs in place include.
Arcadia and Sonoma.
f
City Of Sal I lues OBISp0
COUNCIL AGENDA REPORT
ALTERNATIVE #4
Partnership Between City Fire Department And Private Ambulance Provider.
This alternative would have staff explore the possibility of sub-contracting with the private
ambulance provider for a variety of services. The City would have to retain control of emergency
ambulance operations within the City limits for this alternative to be viable. There are many.
negotiable services such as staffing, billing, equipment, supplies, vehicles and housing that could be
explored prior to implementation. The private provider would retain authority for inter-facility
patient transfers.
Pros
It may be advantageous to develop sub-contracts with the private company. The City could use this
"partnership" to respond to any charges that it was interfering with private.enterprise, yet still take
advantage of a number of the pros outlined in Alternative 3, the Fire-Based Transportation System.
The ambulance company would still be able to recover costs, and continue to collect charges for the
financially lucrative inter-facility transports. The ambulance company would also be able to reduce
expenditures by possibly housing an ambulance inside a fire station.
If a contract was acceptable to the private provider, a potentially expensive and protracted legal
battle could be avoided.
The City could reduce its costs by allowing the private provider to do the billing. They have an
effective and efficient billing system currently in place.
The cost breakdown is similar to the all Fire-Department based transport system described in
Alternative 3.
Cons
The City's major interest is community welfare and cost-recovery. A private provider, while.
sharing these concerns, also needs to show a profit. This is the basis for conflict between the two
entities. The City would have a smaller return from the ALS service which could have a negative
financial impact on the long-term stability of the program.
Without an agreed-upon deadline, protracted negotiations could significantly impact the
implementation of the County-wide ambulance contract.
The role of the Fire Department in emergency transport will always be subject to negotiation. If the
private provider changes, new agreements would have to be made. This results in uncertainty and.
instability surrounding such a vital program.
FISCAL IMPACT
The 1995-97 Financial Plan projected Paramedic revenues at $150,000 annually. The prof. ,
contract specifies reimbursement of$107,500 annually.
A���Il city O� San Luis OBISPO
COUNCIL AGENDA REPORT
CONCLUSION
All parties agree that the current system has many inequities. Staff recommends that we further
develop Alternatives'3 and 4 in order for the City to reaffirm and maintain a position of local
control. We believe this to be important as the prehospital care system of the future is most likely
to expand at the most basic levels, that of field and/or home care. Fire service resources, which are
already in place, can be cost-effectively utilized to fill this expanding need.
ATTACEMENTS
Council Agenda Report dated.9/15/92
; city of San Luis OBISp0
al
KVrZa COUNCIL. AGENDA REPORT
FROM: Robert F. Neumann, Fire Chief
SUBJECT: Confirmation of the City of San Luis Obispo intent to negotiate a new
agreement in the County for the regulation of ambulance services.
CAO RECOMMENDATION:
Adopt a resolution requesting the County to negotiate.a new ambulance agreement between the cities
and the county and designating the City Managers/Fire Chiefs Committee on ambulance as the
bargaining group for the cities.
HISTORY:
Prior to 1976, an organized approach for the delivery of ambulance.service to the citizens of San
Luis Obispo County did not exist. Various cities and districts had individual contractual agreements
with ambulance providers and most of the unincorporated areas of the county were served on a first-
come, first-serve basis. At the urging of the Grand Jury, the County of San Luis Obispo developed
a system known as the EMRM (Emergency Medical Response Manual) that provided various zones
in the county and allowed for the Board of Supervisors to establish rates.
In 1976, the seven cities in the County contractually agreed to allow the County to regulate
ambulance services via the EMRM. The provisions of this agreement called for automatic renewal
every five years unless a city gave one (1) year notice prior to renewal time.
In.May of 1990, the seven cities all notified the Board of Supervisors that they were no longer
happy with the current EMRM system and wished it to be reworked when the contract came due at
May of 1991. The cities took this step at the urging of the Fire Chiefs Association based on a
number of problems and concerns that had developed since the inception of the EMRM. Major
points include:
• No local control • Levels of service not well defined.
• Standards of care not established • No input/process for change
• Duplication of service
All City contracts with the County were terminated by May, 1991. With this contract termination
of the seven County cities and the realization on the part of the County that the entire EMRM was
outdated, the County Health Director commenced a study to analyze the local situation.
Concurrently, the City Managers established a committee to review ambulance service and
emergency medical service as it pertains-to cities. This Sub-Committee, consisting of two City
Managers and two Fire Chiefs developed a proposal that addressed local and fire service concerns
and presented it to the County Health Director and County Administration in January of 1991.
',. f
m� dlhl Hail j �uU�I� city of San WAS OBISp0
COUNCIL AGENDA REPORT
DISCUSSION:
The City Managers Sub-Committee has had numerous meetings with both County administrative
staff and the County Health Director. The group was making significant headway through the
spring of 1992. However, negotiations have completely stalemated with no recent movement. As
late as mid-June, both County administrative staff and the Sub-Committee were optimistic that
County Counsel would bring a draft ordinance forward. However, as of this date, no such draft has
been developed. .
With the current negotiations at a stalemate and with the supplemental documentation from the
Grand Jury, now it is time for the seven Cities in the county to reaffirm their commitment to the
formation of a Joint Powers Agency. This action will allow maximum input, local control, better
coordination and system operation and program"administration of a more effective ambulance
system. In order to accomplish this, staff recommends that the attached resolution, which is being
brought before the other seven cities within the county, be passed. The Fire Chiefs hope that the
increased awareness of this issue will force the Board of Supervisors to take favorable action.
In July of 1992, the Grand Jury released a report that:was very critical of the current system.
A short summary:
• The county-wide 9-1-1 system of ambulance dispatch is inadequate and needs reworking.
• The County has been lax in its oversight responsibilities and the EMRM (ambulance contracts) is
out of date and needs immediate review.
• Emergency/non-emergency ambulance service need to be separated and/or held to different
criteria.
• Ambulance response times in urban area are unacceptable.
• Ambulance rates are the third highest in the state without any compelling reason.
It recommends:
• The County should consider a competitive bidding process for ambulance services.
• Cities, which perform Paramedic service, should be compensated for those services.
• The County should establish a fair rate of return for ambulance service providers.
• The County should rework the current EMRM.
" ' mn�mi9�p city of San tins OBISPO
ffftMe COUNCIL AGENDA REPORT
ALTERNATIVES:
1. Abandon current Sub-Committee negotiations and allow each agency to operate independently in
negotiations with the County Health Director and administrative staff.
Pro - This alternative provides an opportunity to improve service levels and design specific
emergency medical services based on local needs and desires. Each city would
maintain the ability to contract with the County for delivering all Ambulance/EMS
services. The local agency may provide more ambulance units if an increased level
of service is desired and if it is willing to assume the additional cost.
Con - Operating independently, a cost-effective, efficient system will not be developed. The
coordination of mutual aid, large scale emergency/disaster situations all require a
county-wide effort. There is no assurance the County will cooperate with individual
cities.
2. Continue with the current negotiations in hopes of reaching eventual accord with the County.
Pro - The method is easily continued. No expense has or is to be incurred.
Con - The County currently is under no pressure to move at anything other than its own
pace which to this point is unacceptably slow.
3. Adopt the proposed resolution which urges the County to negotiate in good faith with the cities.
Pro - This alternative would force the County to deal with a more formal/united group of
cities. It maximizes local control and allows the cities to jointly coordinate medical
response, system operations and program administration. JPA's have proven effective
in dealing with medical insurance and similar benefits and could potentially do the
same for EMS.
Con - The JPA could require some staff time to develop and implement. The cities
establishment of a JPA may require some financial commitment.
RECOMMENDATION:
Adopt the proposed resolution which urges the County to negotiate in good faith with the cities
(Alternative 3).
All City of San Luis OBISPO
KNiZe COUNCIL AGENDA REPORT
FISCAL rV2ACT:
Other than staff time, no outlay will be required in the onset. Long term fiscal requirements,
depending upon the system design, may be more significant; However, provisions in the contract
would provide for a funding source.
ATTACH1bIE WS:
1. Resolution
2. February 23,, 1989 - Fire Chiefs Letter to City Managers
3. January, 1991 - City Managers/Fire Chiefs.Ambulance Proposal
4. July, 1992 - Grand Jury Report
r
tAb
�
-9
GRAND JURY
COUNTY GOVERNMENT CENTER
SAN Luis OBis.Po, CALIFORNIA 93408
June 24, 1992
Attached herewith for.immediate release is a copy of the
1991-92 Grand Jury Final Report on the San Luis Obispo
County Emergency Medical Services System.
L wrence E. Vandeveer
Foreman
1991-92 Grand Jury
w .
The annual payment to EMSA consists of a "training payment" and an
"administrative payment" with a CPI inflator determined annually.
The primary source of funds used for this payment comes from fines
levied by the courts .
With this contract revision, the County Health Department assumed
major responsibilities in the system. The department designates the
EMSA Medical Director, approves the formal organizational structure
of the system, administers and approves the Emergency Medical
Response Manual (EMRM) and local ambulance codes and ordinances ,
regulates the ambulance/emergency medical transport services , and
designates "Limited Advanced and Advanced Life Support service
providers licensing of private ambulance providers ." • The Office of
the Sheriff/Coroner is the County Licensing Agency for private
ambulance providers (with no visual inspection) . The County Health
Officer also designates the base station hospitals and specialty
care centers , establishes minimum ambulance performance standards
and monitors and approves' the training programs proposed by EMSA.
The EMSA, in consultation with the Health Office, is authorized to
plan, implement and evaluate a Basic Life Support (BLS) and Advanced
Life. Support (ALS) system utilizing EMT-I ' s , EMT-II ' s , EMT-P ' s ,
MICN '.s and First Responder-Defibrillators for the delivery of
emergency medical care . It monitors and provides training programs ,
develops and submits quality assurance - reports on a regular basis ,
prepare state reports , establishes policies and procedures assuring
medical control of BLS, limited ALS and ALS personnel with the
approval of the Medical Director, and act as the County' s Emergency
Medical Care Committee . EMSA also issues certificates of completion
to those persons passing an approved training program and certifies
and recertifies pre-hospital care personnel . Annually, it reviews
the operations of ALS programs and administer disciplinary actions
regarding pre-hospital care personnel .
The EMSA has a Board of Directors made up of members from both the
private and public sector , including a county representative . The
Agency reports to the Director of Health Services of the County.
Chapter 6. 60 , Ambulances , is the County Code which is pertinent to
these services.
Ambulance rates are proposed by provider, evaluated/negotiated by
Auditor/Controller staff who make recommendations through the County
Administrative Offices (CAO) to the Board of Supervisors who approve
rates . During the evaluation/negotiation the provider provides
financial and other data to support this proposal . These is no
requirement for the supplier to provide financial data except at the
time of a requested rate increase.
The following method has been used to establish rates .
1 . Establish allowable expenses plus profit , i .e . , revenue.
Extensive fact finding is performed.
-2-
4 .
I
3 . The Sheriff ' s Office serves as the County Communications Cente:
with a central dispatching system. All "911" calls froi
unincorporated areas go directly to this central dispatc]
center. Emergency . calls from the following go to their 11911'
station before they are communicated to Central Dispatch : Pismo
Beach, Arroyo Grande, San Luis Obispo, Morro Bay, Atascadero
Paso Robles and Grover City. Cal Poly and the California
Highway Patrol both have their own systems and are not part o:
the "911" network.
4 . Emergency calls in .incorporated areas in., the "911" system go ti
municipal dispatchers who use radio to notify their firs
departments (First Responders) , they then notify Centra:
Dispatch which notifies the service providers . This . procedurl
reportedly takes up to three minutes to complete .
S . The California Department of Forestry (CDF) has county firs
department personnel based at the following CDF stations
Shandon, Paso Robles , Park Hill (Santa Margarita) , California
Valley, Cambria , Cayucos , San. Lui.s Obispo, Nipomo and San Lui:
Obispo Airport . .
6. Emergency calls from unincorporated areas go to Central Dispatc]
whish then notifies the appropriate CDF station and the assignee
service provider .
7 . Emergency response times ' for ambulances in urban areas have
suggested compliance responses of 90% at eight minutes and 95'
at ten minutes . In 1991 , only four urban areas met bot]
criteria. Two areas met the ten-minutes criterion and seven dii
not meet either criteria. Ambulance response times for rura:
areas vary according to their distance from the ambulance base
station.
8. The number and location of paramedics in the county as of Apri.
139 1992 , were as follows:
a) City paramedics : San Luis . Obispo, 15 ; Atascadero, 8; Morr,
Bay., 3 . plus 2 interns ; South Bay, 5 plus 2 interns
Cambria District had 5 paramedics .
b) Ambulance company paramedics : San Luis Ambulance Company
15 ; Five Cities Ambulance Company, 6 plus 3 part time
Special Services Ambulance Company, 1 .
c) The county fire department has no paramedics .
9. The CHP certifies the ambulances , performing a physica
inspection of the vehicle and BLS equipment .
10. The SMSA does a cursory annual inspection of vehicles eac
January on a scheduled basis . This appears to be an inadequat
inspection procedure for ambulance units and their equipment .
-4-
17. The jury could not find any compelling reason for this county' s
rates to be third highest in the state .
CONCLUSIONS
1 . The jury concludes that medical transport of patients not
requiring BLS or ALS services should not be required to meet the
same criteria as ambulance use whenever these life support
systems are required by the patient.
2 , The current "911" system of ambulance dispatch can use up a
significant amount of critical time when patients are extremely
vulnerable.
3 . Ambulance emergency response times in urban areas should meet
the eight-minute and ten-minute response criteria without fail .
4 . CDF stations in rural areas need to upgrade some of their staff
to the paramedic level and provide the necessary basic equipment .
S . A study by current city/county staff members to determine the
feasibility of a central 11911" center for all of the county
would be beneficial . The savings in time and money, both
critical issues , could be substantial .
6 . Ambulance units should be inspected on_ a random, unannounced
basis at least quarterly to ensure complete compliance with
health and safety standards which truly protect citizens .
Disciplinary actions for non-compliance should be sure and
prompt .
7 . The EMRM should be immediately reviewed and updated . It appears
the county has been lax in its oversight responsibilities here
as well as in most other areas of the system,
RECOMMENDATIONS
1 . The county should consider competitive bidding for ambulance
services .
2 . The county, through the EMS agencies , should take immediate
steps to establish policies and procedures ensuring pre-hospital
emergency medical service vehicles are maintained in a clean and
sanitary condition so that the health and safety of patients is
not unduly at risk.
3_. The county fire department should upgrade its staff so that
paramedic services are more quickly accessible in rural areas .
4 . The county and cities in the 11911" system should participate it
a feasibility study of a centralized "911" station as a means of
reducing ambulance response times .
-6-
i
yo.0 I cil agenda report routing slip7
'17 9/3/02
Renort Title
Ambulance Contract Reimbursement
O Public Hearing ❑Business ElConsent ❑Appointment ❑Presentation O Study Session
Prepared By: Dept.
Viv R.DiltsHead: Wolfgang Knabe,Fire thief
— --
ROUTING
ORDER DEPARTMENT DATE IN DATE OUT INITIALS
Human Resources
I Finance
Z City Attorney
3 -_ Asst.to CAO
4 CAO
5 City Clerk
Checklist
Check all that apply:
❑All attachments are labeled
El The electronic file pathis indicated on the Report.
❑ One(1) unmarked original Agreement/Contract and one(1) clearly labeled copy attached
❑Ordinance Synopsis emailed to the Office of the City Clerk
❑Council Reading File materials attached (please list):
Return Council Reading File materials to Dept.
Reviewer Comments:
l.kAaenda Report TemolatesCAaenda Report Routing Form Print this form on Yellow Parer
AGREEMENT FOR ASSIGNMENT OF BILLING RIGHTS
FOR FIRST RESPONDER SERVICES
This Agreement for Assignment of Billing Rights for First Responder Services ("Agreement"v
by and between the City of San Luis Obispo, a municipal corporation ("City') and San Luis
Ambulance Service, Inc., a California corporation ("SLAS") is entered int"n the date set forth below.
Collectively,the parries to this agreement are referred to as "the parties"
RECITALS
WHEREAS, SLAS is party to a April 16, 2002 agreement with the County of San Luis Obispo
to provide ambulance services within the County of San Luis Obispo; and
WHEREAS, Article 4 of the April 16, 2002 agreement with the County of San Luis Obispo
provides that SLAS shall make certain payments to the City in exchange for a general assignment of
the City's rights to bill persons for certain services provided by its fire department in connection with
emergency calls for medical assistance; and.
WHEREAS, City's fire department meets minimum Advanced Life Support Services
requirements and/or EMT-D qualifications as set forth by the County of San Luis Obispo's Emergency
Medical Service Agency; and
WHEREAS, Article 3 of the April 16, 2002 agreement with the County of San Luis Obispo
provides Performance standards utilizing City's First Responder Advanced Life Support and/or EMT-D
services in meeting SLAS deployment plan goals;and
WHEREAS, Article 4 of the April 16, 2002 agreement with the County of San Luis Obispo
requires that the parries to this Agreement enter into a separate written agreement providing for
assignment of the City's rights to bill persons for these services.
NOW, THEREFORE, IN CONSIDERATION OF THE PROVISIONS SET FORTH BELOW, THE
PARTIES AGREE AS FOLLOWS:
1. Definitions: The parties hereby incorporate by reference all definitions set forth in
Article 1 of the April 16, 2002 agreement between SLAS and the County of San Luis Obispo (Exhibit
A).
2. Assigmments: City hereby assigns its rights to SLAS to directly bill persons for first-
response emergency medical services provided by its fire department in connection with emergency
calls for medical assistance. First-response emergency medical services provided by the City's fire
department include, but are not limited to, providing initial stabilization and trained on-scene
assistance, and assistance en-route to medical facilities as required, and extrication and rescue services.
3. Timing and Amount of First Responder Payment: The Contractor shall make the first
responder payments shown in Exhibit B, attached hereto. CITY because it has implemented ALS
service and meets the minimum ALS requirements as outlined by the local EMS Agency shall be paid
for services between January 1, 2002 and June 30, 2002 according to the payment schedule set forth in
Exhibit 2. All first responder payments shall be made no later than the end of the second month
following the end of the quarter for which the payment accrued(for example,payment for the period of
April Is`through June 30ffi will be due on or before the following August 30').
4. Annual Adjustment to Payments: The quarterly payments to the first responder
agencies will be adjusted annually, effective July 1, 2003, and annually thereafter, in proportion to the
change in the Los Angeles-Riverside-orange County Consumer. Price Index. However, in no event
shall the annual increase exceed five percent (5%). The indexes shall be for All urban Consumers as
published by the Bureau of Labor Statistics.
5. Equipment Exchange and Replacement: SLAS shall establish a restocking plan and
replenish disposable medical supplies and equipment used by CITY in connection with each patient
transport.
6. Indemnification: SLAS shall defend, indemnify, save and hold harmless the City and
its officers and employees from any and all claims, costs and liability (including without limitation,
attorneys' fees) for any damages, sickness, death or injury to person(s) or property, including without
limitation all consequential damages, from any cause whatsoever arising directly or indirectly from or
connected with the operations or services of SLAS or its agents, servants, employees or subcontractors,
save and except claims or litigation arising from the sole negligence or sole willful misconduct of the
City or its officers or employees.
7. Term: The term of this Agreement shall coincide with the ambulance agreement
between the County and SLAS. Agreement shall be five years, with three one-year extension options
commencing April 2002. Unless this Agreement is terminated by either party pursuant to this
Agreement, the term of this Agreement shall be automatically extended for a period not to exceed
twelve months. During this extension period, the Agreement shall remain in full force and effect as to
all terms and conditions as applicable during the original five-year period of the Agreement. If the
Agreement is extended as provided, SLAS shall continue to make payments as set forth above, and
City shall continue to assign its rights to directly bill persons for emergency services rendered by its fire
department.
8. Early Termination: This Agreement may be terminated by either party, in its sole
discretion, upon one hundred eighty days' advance written notice to the other party. This Agreement
may be terminated immediately upon written mutual agreement of the parties. Furthermore, City may
terminate this Agreement immediately should the County of San Luis Obispo terminate its March 26,
1996 agreement with SLAS as provided in Section 7.3 of that agreement.
9. Modification: This Agreement may be modified or amended only by a written
document executed by the City and SLAS. This Agreement contains all the terms and conditions
agreed upon by the parties. Except as expressly provided for in this Agreement, not other
understanding or representation, oral or otherwise, regarding the subject matter of this Agreement, shall
bind or affect either of the parties.
The foregoing agreement was adopted this _ day of ,2002.
Mayor Allen ettie President and CEO Frank Kelton
City of San Luis Obispo San Luis Ambulance-Service, Inc.
ATTEST:
City Clerk
APPROVED AS TO FORM:
ptTorney
EXHIBIT A
ARTICLE l:DEFINITIONS
For the purpose of this agreement, all words and phrases that are defined in section
6.60.010 of the San Luis Obispo County Code shall have the meaning ascribed to them in said
section of the County Code and are incorporated herein by reference. The following words and
phrases that are not defined in section 6.60.010 shall have the following meaning:
Advanced Life Support(ALS): For ambulance services,means special services
designed to provide definitive prehospital emergency medical care, including but not limited to,
cardiopulmonary resuscitation, cardiac monitoring, cardiac defibrillation,advanced airway .
management, intravenous therapy, administration of specified drugs and other mechanical
preparations,and other medicinal preparations, and other specified techniques and procedures
administered by authorized personnel under the direct supervision of a base hospital as part of the
local EMS system at the scene of an emergency during transport to an acute care hospital and
during interfacility transfer.
ALS Provider: A public or private provider officially designated by the County Health
Officer as an entity..authorized to operate ALS Units and provide ALS services in San Luis
Obispo County.
APOC: The San Luis Obispo County Ambulance Performance/Operations Committee,
created pursuant to section 6.60.050 of Chapter 6.60.
Ambulance Service Area: The Northern;Central, and Southern Ambulance Service
Areas are the geographical areas of the Countythat are separately defined in E)d6it A, attached.
hereto and incorporated herein by this reference.
Basic Life Support(BLS): Emergency first aid and cardiopulmonary resuscitation
procedures which as a minimum include recognizing:respiratory and cardiac arrest and starting
the proper application of cardiopulmonary resuscitation to maintain life without invasive
techniques until the victim may be transported or until advanced life support is available:
Chapter 6.60: Chapter 6.60 of the San Luis Obispo County Code("Prehospital
Emergency Medical Care and Transport.Services").
Contract Manager: The County's Public Health Agency Director, or designee, or
successor in responsibility.
County: 'The County of San Luis Obispo.
Emergency: A condition or situation in which an individual has a need for immediate
medical attention or where the potential for such need is perceived by emergency medical
personnel or a public safety agency.
EMS Act: California Health and Safety Code Sections 1797 et seq., or successor
'legislation on the same subject.
EMSA, Inc.: The San Luis Obispo Emergency Medical Services Agency, Inc., a
California nonprofit corporation. EMSA, Inc. is not the Local EMS Agency but it does perform
certain functions for the Local EMS Agency pursuant to a contract with the County.
EMS System: A system of organizations,resources and individuals from whom some
action is required to ensure a timely and medically appropriate response to medical emergencies.
First Response Organization: Typically a public agency, such as a fire department,that
responds to emergency calls for medical assistance,providing initial stabilization and trained
assistance on-scene and,when required, en route to medical facilities; also refers to certain
extrication and rescue services. In accordance with priority dispatch protocol, a first response
unit is routinely sent to all presumptively classified life-threatening calls within the ambulance
contractor's service area.
Incident Command System: The combination of facilities equipment,personnel
procedures, and communications operating within a common organizational structure,with
responsibility for the management of assigned resources to effectively accomplish stated
objectives pertaining to an incident_
Life Threatening Emergencies: Those situations determined in accordance with local
medical direction that are likely to result in the loss of life without immediate intervention.
Local EMS Agency: The Public Health Agency of the County of San Luis Obispo,
under the direction of the Public Health Agency Director,or its successor in responsibility(in the
event of a reorganization affecting the Public Health Agency).
Local EMS Plan: The emergency medical services plan adopted by the Local EMS
Agency pursuant to the requirements of the EMS Act.
Medical Control: The medical management of the emergency medical services system
pursuant to the provisions of Health&Safety Code chapter 5, sections 1978 et seq.
Non-Life Threatening Emergencies: Those medical emergencies determined in
accordance with local medical direction,not likely to result in the loss of life.
Public Health Agency Director: The Public Health Agency Director of San Luis
Obispo County.
Medical Director: The physician under whose license and authority EMTs and
Paramedics provide services.
Paramedic: An individual trained and licensed to perform advanced life-support
procedures under the direction of a physician.(Also referred to as an EMT-P.)
Paramedic Ambulance: An ambulance staffed by a minimum of one licensed
paramedic and one certified EMT and equipped to provide advanced life support(ALS).
Transport: When a patient is transported by ambulance to a hospital or between medical
facilities where.the medical capabilities of an ambulance are required or potentially required..
ARTICLE 2.DESIGNATION AS PROVIDER AND „
DESCRIPTION OF SERVICES TO BE PROVIDED
o
2.1 Services-In General.Pursuant to Chapter 6.60,the County hereby designates the
Contractor as the Ambulance Service Provider for the Northern-Central Ambulance Service
Area. Within each of said Ambulance Service Area, the Contractor shall provide emergency
ambulance service without interruption,24 hours per day, every day, for the full term of this
contract,in accordance with all provisions of this contract. The Contractor shall provide said
emergency ambulance services without regard to the patient's race,color,national origin,
religious affiliation, age, sex, or ability to pay.
_...,.2,2__Applicable.Standards'and.Involved Agencies. The Contractor shall provide...
Advanced Life Support("ALS")emergency ambulance services under Medical Control as
dispatched by MED-COM. Such services shall be provided in accordance with the requirements
of the EMS Act, Chapter 6.60,the Local.EMS Plan, this contract, and any other applicable
statutes, ordinances and regulations. In performing services hereunder, the Contractor shall work
cooperatively with the Local EMS Agency. The Contractor shall also cooperate with APOC and
SMSA,Inc.with respect to matters within their purview.
23 Air Ambulance Transport.The County reserves the right to enter into separate
transport agreements with air ambulance providers.Notwithstanding any other provision of this
Agreement,the County may provide for air transport of patients when such transportation is
deemed by the most senior medical personnel on the scene to be in the best interest of the
patient(s).However,no such agreement shall provide for air transport of non-critical patients or
of critical patients when a ground ambulance is on-scene and transport time by ground
ambulance to the most accessible emergency medical facility equipped,staffed,and prepared to
administer care appropriate to the needs of the patient is the same or less than the estimated air
transport time.
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-- OFFICE OF THE ASSISTANT
k JAC A.CRAWFORD
COUNTY COUNSEL
a� CHIEF DEPUTY
COUNTY OF SAN LUIS OBISPO R.WYATT CASH
COUNTY GOVERNMENT CENTER ROOM 386
SAN LUIS OBISPO,CA 93408 DEPUTIES
TELEPHONE(805)781-5400. JAMES B.ORTON
-0221 WARREN R JENSEN
FAX(805)787
- RAYMOND A.BIERING
PATRICIA A.STEVENS
JAMES B.LINDHOLM.JR KATHY BOUCHARD
TIMOTHYMCNULTY
COUNTY COUNSEL September 25, 2003 ANN CATHERINE DUGGAN
PATRICK J.FORAN
LESLIE H.KRAUT
RRA L.NEAL
PATRICIA GOMEZ
STACY MILLICH
VIRGINIA SAWYER RADDING
By Facsimile 543-1205
P. Terrence Schubert
Attorney At Law
1254 Marsh Street
San Luis Obispo, CA 93401
Re: First Responder Fees
Dear Terry-
It has come to my attention that your client, San Luis Ambulance, Inc. ("SLAS')has
failed to pay the first responder fees which were due to all first responders on or before
August 30, 2003. 1 have further been informed that your client has indicated that he is not going
to pay those fees.
Please note that failure to pay the first responder fees is in direct violation of the contracts
that your client signed with the County in April of 2002. As you will recall, a great deal of time
and effort went into negotiating the first responder fees and significant input was received from
APOC and the fire agencies regarding these fees. It is extremely unsettling at this point that your
client has.failed to make the payments. Please notify your client that the County expects this
potential breach of contract to be remedied immediately. Failure to do so may cause the County
to initiate termination for cause pursuant to Paragraph 7.3 of the contract.
I recognize that you have recently requested that the County review the first responder
fees and consider requiring the air ambulance provider to pay first responder fees. The County is
currently reviewing that request and will respond in the next few weeks. However, such request
does not alleviate your client's responsibility to comply with the contract terms.. Please note that
first responder fees were considered as part of the recent rate reviews and were considered in the
determination to allow your client to raise the ambulance rates.
I
P. Terrence Schubert
Re: First Responder Fees
September 25, 2003
Thank you for your immediate attention to this issue.
Very truly yours,
JAMES B. LINDHOLM,.JR.
County Counsel
By: Rita L.Neal
Deputy County Counsel
RLN:mj a
cc: Chief Dan Turner, CDF& SLO County Fire Department
Chief Wolfgang Knabe, San Luis Obispo Fire Department
Chief Douglas R. Hamp;Paso Robles Fire Department
Chief Kurt Stone, Atascadero Fire Department
Chief J.M. "Mike"Ellison, San Miguel Fire Department
Chief Greg O'Sullivan,Templeton Fire Department
Chief Dan Turner,Avila Beach Fire Department
Chief Bill Radke, Cayucos Fire Department
Chief Jeff Jones, Morro Bay Fire Department
Chief Bruce Pickens, South Bay Fire Department
—-- ---Mef-Terry-Fibieh-Arroyo-Grande-Fire-Depar-tment - - -— -- -- --- —----—
Chief Jack Criswell, Grover Beach Fire Department
Chief Dan Turner,Pismo Beach Fire Department
Chief Chris Marshall, Oceano Fire Department
Thomas Lynch,EMSA,Inc.
Gregory Thomas,M.D.,Health Agency
Kathleen O'Neill, Health Agency
David Edge, County Administrative Officer
6893njaltr.wpd
-2-
VVIco Caw _
JFRFAUG
I-0O2 HEALTH DIRECTOR
ORDINANCE NO. 2629
ORDINANCE AMENDING SAN LUIS OBISPO�QUNTY
ORDINANCE CODE SEMON 6.60 COI CERlq!NG
REGULATION OF ANIBULANCES.`
The Board of Supervisors of the County of San Luis Obispo, State of California, does
ordain as follows:
SECTION I: That Section 6.60 of-the County Code be amended to read as follows:
PRE-HOSPITAL EMERGENCY MEDICAL CARE AND TRANSPORT SERVICES
Sections:
6.60.010 Definitions.
6.60.020 County ambulance provider agreements.
6.60.050 Ambulance Performance/Operations Committee.
6.60.060 Ambulance rates.
6.60.070 Financial responsibility.
-6.60.010 Definitions. As used in.this chapter, the following words and phrases have
been patterned after the meaning ascribed to them in the National Association of EMS
Physicians(NAEMSP)Medical Director's Handbook,hereafter referred to as the"NAEMSP
i r
Glossary". In particular, the following terms shall havethe following meaning:
Q4` <
l J
(1) "-Ambulance"is defined as a vehicle certified by the California Highway Patrol
or other applicable state authorities as meeting specifications for transporting and caring for
patients. This term generally refers to a wheeled vehicle, but may include boats, planes,
helicopters, and other specialized vehicles. A Type I ambulance consists of a truck cab-
chassis with a modular body that allows for replacement of the chassis and reuse of the
modular body. A Type II ambulance consists of a.standard van-forward control=integral cab-
body unit A Type.III ambulance is a specialty van with forward control and usually with
the ability to walk through from front.
(2) "Ambulance service provider" means any private or public entity or person
operating, owning, or controlling one or more ambulances, in a contractual agreement with
the County of San Luis Obispo
(3) "Ambulance service area" means those ambulance service areas established
within the county and designated in individual County ambulant: service provider
agreements.
(4) "Board" means the Board of Supervisors of the County.
(5) "Central dispatch"means the San Luis Obispo County medical communication
system (IVIED-COM) dispatch point.
(6) "County" means the County of San Luis Obispo.
(7) 'Dispatch time"means the interval from when a request for an ambulance is
received by central dispatch until the ambulance is notified
(8) "Local EMS Agency" means the County Health Department.
(9) "Emergency call"means a request for assistance that activates the EMS system.
It may come through a variety of mechanisms: voice, regular telephone, 911, or radio.
(10) 'Emergency rescue vehicle" means any privately or publicly owned motor
vehicle, boat, aircraft, that is specially constructed, modified, equipped or arranged, and
operated, that would aid-in life saving activities in the event of, a sudden, generally
unexpected occurrence demanding immediate action.
(11) "EIVP mr means an Emergency Medical Technician I as defined in Health and
Safety Code_Section 1797.80 and 22 California Code of Regulations Section 100063.
(° (12) ' "EMT-D": An Emergency Medical.Technician:-Defibrillator, an EMT-I with
1 . additional training,to perform cardiac defibrillation on unconscious, pulseless and apneic
patients, as defined by 22 California Code of.Regulations Section 100064.
(13)' "EMT-P"means Emergency Medical Technician-Paramedic..An EMT-A with
additional training to the full advanced life support level, as defined in Health and Safety
Code Section 1797.84 and 22 California Code of Regulations Section 100138.
(14) "First Responder"means the first individual to arrive at the scene certified to
render medical care in response to an emergency call.
(15) "UM-COM'means the radio,telephone and dispatch system equipment that
makes up the San Luis Obispo County medical communications system.
(16) 'Patient" means a wounded, injured, sick, invalid, convalescent, infirm, or
otherwise incapacitated person requiring immediate medical attention and/or presenting,a
significant probability of requiring medical care while being transported, as judged by the
most highly medically qualified person at the scene.
(17) . Remote Area: AD areas of the County which have a population density of
.9 personsor less per square mile.
(19) 'Response Code": "Code I" means an ambulance is to arrive at its destination
at the earliest convenience. "Code II" means an ambulance is to proceed to destination as
rapidly as possible, obeying traffic laws. "Code III"means an ambulance is authorized to use
a red warning light and siren.
(20) 'Response time"means the interval of time from ambulance notification until
the ambulance is at the scene.
(21) Rural Area: All definable community areas of the County with a population
of less than 2,500 and population density of 10 to 99 persons per square mile:
(22) Urban Area: All definable community areas of the County with a population
of 2,500 to 500,000 and a population density of 100 or more persons per square mile..
6.60.020 County ambulance- service providera ergs ement. No individual,
-partnership, corporation, or other entity shall operate, conduct, advertise, or otherwise be
engaged in the business or service of the transportation of patients upon the street, or any .
public-way or place within the county, unless the County, through.the Board of Supervisors,
..has executed.a written County ambulance service provider agreement withsaid individual,
"1 partnership, corporation, or other entity. An ambulance operated by an agency of the
United States or by the state shall not be required .to have such an agreement
1) The County ambulance service provider agreements with private providers shall
provide for some method of ensuring that in the event the provider ceases to perform the
agreement for any reason (including insolvency, bankruptcy, voluntary or involuntary
dissolution of the business) the ambulances and operating equipment used by the provider
in carrying out the agreement will be available for use by the County, or another private
provider operating under agreement with the County, free of any legal encumbrance. Said
provisions may take the form of county ownership with lease back arrangements or some
other method, as recommended by the Ambulance Performance/Operations Committee.
2) The agreements shall address other areas of operation and performance, including
but not limited to coverage requirements, minimum response time standards, staffing and
certification requirements, review of financial and other records, data collection and
reporting requirements, system interaction and rates.
3) The agreements will be developed by the Ambulance Operations/Performance Review
j Committee before submission to the Board of Supervisors for approval on behalf of the
County.
4) During the term of any agreement, proponents of any additional provider service in
any of the assigned ambulance service areas shall have the burden of demonstrating that the
public health, saftey and welfare require the additional service.
6.60.050 Ambulance Operations/Performance Committee. An Ambulance
Operations/Performance Committee is hereby created, to be organized as follows for the
purposes set forth below.
1) The Ambulance Operations/Performance Committee shall consist of seven members,
three who shall be appointed by the County Administrator, and four who shall be appointed
by the City Managers, of which at least two shall be Fire Chiefs. The committee members
appointed by the City Managers shall each be approved by a majority of the City Managers
of the incorporated cities located within the County. .None of the members shall be
employees, officers, agents, or owners of any of the..priyate ambulance service providers.
The members shall serve indefinite terms at the.discretion of their appointing authority. The
w
11
Committee will be.assisted in certain clerical functions by the County of San Luis Obispo.
2) The purpose of the Ambulance Operations/Performance Committee is to assist the
County Board ,of Supervisors in developing and administering policy an all. aspects of the
pre-hospital emergency medical services system, including but not.limited.to the following:
a) The service levels and response capabilities of ambulance providers in the
county.
b) The development and oversight of contractual relationships between the county
and ambulance service providers.
c) The development and oversight of agreements between the cities of San Luis
Obispo County and the County of San Luis Obispo.
d) The rate structure of ambulance providers, and the services and financing of
EMS first responder agencies.
e) The development and maintenance of ambulance performance standards.
f) The development and oversight of ambulance service areas.
3) The Ambulance Performance/Operations Committee may develop such bylaws as it
L- determines necessary for the performance of its duties as outlined above. Bylaws, once
determined, shall be -referred to the. Board of Supervisors for its consideration
and approval.
6.60.060 Arnbulance rates. (a) Any ambulance service provider which operates
within the unincorporated territory of the county shall not charge any rate until that rate has
first been approved by the Board of Supervisors through inclusion of the rates in provider
agreements approved by the County.
(b)All County ambulance service providers doing business within the unincorporated
territory of the county shall.maintain a schedule of their current rates in each ambulance
that they operate.
(c) This section shall not apply to.services provided by any public entity responding
within that public entity's jurisdictional boundary.
6.60:070. Fnancial resnon: si Iity As required by Title 13 of the California Code
"�a . of Regulations Section 1106.2, no owner shall use any ambulance, or permit any ambulance
�: to:lie used, to.;transport passengers for hire without maintaining the ability to respond in
l�
damages as required by Vehicle Code Section 16500.
SECTION II: This Ordinance shall take effect and be in full force and effect thirty
days after its passage; and before the expiration of fifteen (15) days after passage of this
Ordinance, it shall be published once with the.names of the members.of. the Board.of
Supervisors voting for and against the Ordinance in the Telegram-Tnbune, a newspaper of
general circulation published in the County of San Luis Obispo, State of California.
INTRODUCED at a regular meeting of the Board of Supervisors held on the 27th
day of Ju1v , 1993, and PASSED and ADOPTED by the Board of Supervisors of
the County of San Luis Obispo, State of California, on the 3rd day of August , 1993,
by the following roll call vote, to-wit:
AYES: Supervisors David Blakely, Laurence L. Laurent, Evelyn Delany,
NOES: Ruth E. Brackett, Chairperson Harry L. Ovitt
None
ABSTAINING None
the following ordinance is hereby adopted
r
HARRY
L,OVITF
Chairman of the Board of Supervisors of the
County of San Luis Obispo, State of California
ATTEST:
Cid M COONEY
County Clerk and Ex-Officio Clerk of the
Board of Supervisors, County of
San Luis Obispo, State of California
[SEAL]
r\
R
f 1
,.... ORDINANCE CODE PROVISIONS APPROVED
AS TO FORM AND CODIFICATION:
JAMES B. LINDHOLM, JR
County Counsel
By �
County Counsel
Dated: 7�Z z�� 3
_LindikKirby-03-19-96.MIN.doc Page 8
City Council Meeting Page 8
Tuesday,March 19,1996-7:00 p.m.
Arnold.Jonas, Community Development Director; said that this analysis of the power blower
regulations had been requested by Council at their last review of this issue, and proceeded to
outlined the ordinance proposed this evening.
Mayor Settle opened the public hearing.
Alan.Friedman,San Luis Obispo,disagreed with the staff recommendation and urged Council to ban
gas Blowers in the City.
Terry Lee. Good Green Earth Landscaping, said he had never had one complaint about use of
blowers and said that pursuing the educational program was a good idea.
Nick Tennis,Camacho and Tennis Landscape;objected to the certification program.
Kevin Holmes, West Coast Landscapes, asked Council to take no, further action at this time
regarding the use of blowers.
Mayor-Settle closed the public hearing.
After discussion, moved by Williams/Romero to make no make no change to existing regulations;
motion carried(3-2;Council Member Roalman and Mayor Settle voting no).
BUSINESS ITEMS
6. AMBULANCE NEGOTIATIONS(File No.725)
Council considered developing a new ambulance concept which includes reimbursement for Fire
Department first responders, a rental agreement with San Luis Ambulance for shared use of new
Fire Station#1,and City participation in the Emergency Medical Dispatch Program.
Bob Neumann, Fire Chief,said that this very difficult and complex issue had been in the works for
ma6y years, with many people joined together in the Ambulance Performance Operations
Committee,a county-wide group that is an advisory body to the Board of Supervisors.
Mayor Settle asked if anyone in the audience wanted to speak on this issue.
Gary Fowler,San Luis Obispo,urged Council not to approve the staff recommendation.
Charlie Noffin,San Luis Obispo,said that increasing ambulance costs was a terrible idea.
Robert Fuller.Vice President of San Luis Ambulance, explained the need for the rate increase and
said that the company delivers fine care.
Mayor Settle returned discussion to the dais.
Moved by Roalman/Romero to: 1) support the recommendation of the.Ambulance Performance
Operations Committee which includes the development of a new ambulance contract;2)direct staff
to prepare a rental agreement between the:City and San Luis Ambulance, Inc.for shared use of the
new Fire Station,#1 at an estimated return of$18,000;3)approve City participation in the Emergency
Medical Dispatch Program; and 4)appropriate a net amount of$4,800 to complement the proposed
` Linde,,Kirby-06-04-96.MIN.doc Page 2
City Council Meeting Page 2
Tuesday,June 4,1996-4:00 p.m.
Moved by Smith/Williams to waive oral reading and approve minutes as amended; motion carried(5-
0).
C2. CAPITAL IMPROVEMENT BOARD-ANNUAL.MEETING(File No.214)
Council considered the minutes of the Annual Meeting of the Capital Improvement Board.
Moved by Smith/Williams to 1) approve minutes of the meeting held on April 16, 1996; and, 2)
adjourn to the next regularly scheduled meeting;motion carried(5-0).
C3. WATER REUSEPROJECT(File No.526)
Council considered the Water Reuse Project—Biological Resources Mitigation Plan.
Moved by Smith!Williams to approve,and authorize the Mayor to:sign,addendum 4 in the amount of
$18,903.60, to a contract with Fugro West Inc. for "Water Reuse Project-Evaluation of Biological
Resources';motion carried(5-0).
C4. AMBULANCE CONTRACT REIMBURSEMENT(File No..725)
Council considered the contract with San Luis Ambulance Services,Inc.
Moved by Smith/Williams to approve contract with San Luis Ambulance Services, Inc., authorizing
them to bill persons for first-response emergency medical services provide by the Fire Department
and authorize the Mayor to execute the contract;motion carried(5-0).
C5. SAFETY.ELEMENT UPDATE(File No.462)
Council considered the Safety Element Update Joint Powers Agreement.
Moved by Smith/Williams to approve,and authorize the Mayor to execute,a joint powers agreement
(JPA)with the County and participating cities,for updating the General Plan Safety Element,with the
City's costshare of consultant services to be$16,671;motion carried(5-0).
BUSINESS ITEMS
1. MULTI-MODAL_TRANSIT TRANSF.ER,CENTER,(File No..549)
Council considered the Multi-Modal Transit Transfer Center.
Mike McCluskey,Public Works Director,reviewed the agenda report.
Harry-Watson,Transit Manager,and Alan Cantrell. County Regional Transit Manager,demonstrated
the new bus routes that would be traversed by City and CCAT buses if the transfer center were at
the Amtrak location,
Mayor Settle asked for comment from the public.
Pierre.Rademaker. speaking as a member of both the Downtown Design Team and the BIA,said it
would be Important to maintain services.levels to the core of the City.
Steve.Devencenzi. San Luis Obispo Council of Governments (SLOCOG), asked the City to ad a
recommendation to direct staff to work with the County to develop a cooperative agreement
Page 1 of 2
Wolfgang Knabe Interesting article
From: "Laurie Phillips" <Iphillips@thetribunenews.com>
Tod <wkhabe@slocity.org>
Date: 3/11/2004 10:17 AM
Subject: Interesting article
Chief'Knabe, I saw this on the wire this morning and thought you'd be
interested.I'm.eager to know what you think. -- Laurie
By.Matthai Chakko Kuruvila
San Jose Mercury News
Feeble and in need of a doctorCis appointment in Palo Alto?Why be carted
around by family when you can take an ambulance?The city0s fire
department; hoping to snare extra cash during lean budget times, has
launched a service to transport.fragile patients to hospitals, doctors
offices,rehab centers or convalescent facilities.
It ainOt cheap N a minimum $350 one-way, plus$15 a mile. But itOs
cheaper than calling for most private ambulance companies, which has
some in the industry griping.
With Medicare, insurance and patients toting the bill, city officials
are confident the weekday service will grow in popularity.
OThis is an entrepreneurial effort by us to help recover the costs of
providing fire service and lessen the burden to the taxpayer,0 said Fre
Chief Ruben Grijalva,who believes his department is the first in the
Bay Area to pursue such services.
This is, by the way, the same fire department that makes over$15,000 a
year by using its Web site to sell everything from $35 gym bags to $15
knitted beanie caps N all emblazoned with the words OPalo Alto Fire.0 In
a budget year where the city council slashed $180,000 in overtime pay
from the fire department, every bit counts.
Some who oversee care of the elderly believe the new program,might well
be worth it
OMy feeling is that$350 is probably a bargain,0 said Wendy Frye,who
owns 6-bed Birches Residential Care in Palo Alto. 01 wouldnOt hesitate
to use that service for one of my clients or one of my family, if that
were called for.0
This is no taxi service.The trips require a prescription from a doctor,
unless you want to pay entirely out of pocket The service is tailored
toward, among others, recent stroke victims or patients being discharged
from a hospital. Medicare and insurance already approve coverage of most
of the costs.
Because they only provide service within Palo Alto,Grijalva insists the
department isnOt trying to compete with private ambulance companies.
OThatOs not accurate at all,0 exclaimed Matt Edwards,spokesman for
Livermore-based American Medical Response, the nation0s largest
ambulance company, which also serves Santa Clara County.
Edwards worries the fire departmentOs relatively cheaper service could
drive down rates in an industry where he says ambulance services recover
only 73 percent of what they bill. He said decreasing rates could send
rippling effects through the entire health care industry.
But Palo Alto sees this as a way to make government self-sufficient.
Despite other money-making efforts, the fire department recovers only 44
file://C:\Documents%20and%2OSettings\slouser\Local%2OSettings\Temp\GW?OOOOI.HTM 3/11/2004
Page 2 of 2
percent of its costs. And the$1.6 million they take in for 2,200
emergency calls annually accounts for only 70 percent of whatOs billed,
Grijalva said. No one is turned down for a 911 call; regardless of their
ability to pay.
With two appointments a day, which they now have, Palo Altobs new
service breaks even. With four appointments a day, the fire department
would earn $250,000 a year in profit N which would support other
department services.
With more than 50 hospitals, nursing homes and medical offices in the
city, Gnjalva said, OI think there6s capacity out there for much more
than four calls a day.0
Those making 911 calls shouldnOt worry about added delays. The new Basic
Life Support Service operates independently from the departmentOs
current emergency ambulance service.
Scheduling non-emergency transportation is one month into a six-month
trial period. If it works, it will be continued.
To schedule service anywhere in the Palo Alto area, call the city6s fire
department at(650)329-2540.The service is available weekdays from 7
a.m. to 5 p.m.
Contact Matthei Chakko Kuruvila at mkuruvila@mercurynews.com or(650)
688-7581.
file://C:\Documents%20and%20Settings\slouser\Local%20Settings\Temp\GW}000O1.HTM 3/11/2004
PREHOSPITAL POLICY
Policy Reference No: 104
Effective Date: 3/1/97
Supersedes: Section 2,Page 25
SUBJECT: COUNTY-WIDE AMBULANCE MOVE-UP PROCEDURE
1. PURPOSE:
To establish a procedure that, through the movement of ambulance units, assures
the least possible response time to EMS calls by ambulance resources. This
procedure will act as a guide for the County Ambulance Dispatch Center(Med-
Com).
II. PROCEDURE:
A. Anytime an ambulance service area has no available ambulances,Med-
Com shall make every effort to move available ambulances to
predesignated locations to reduce the response time to the uncovered area.
B. The predesignated ambulance staging areas shall be:
1. Avila Road to cover areas five and six
2. Highway 58 and 101 to cover areas four and five
3. Cuesta College to cover areas three and five
4. Via Creek and Highway 1 to cover areas one and three
5. Twin Cities Community Hospital to cover areas two and four
6. Highway 46W and Vineyard Dr. to cover areas one and two for a
unit stationed in Paso Robles.
7. Highway 46W and Cypress Mountain Rd. to cover areas one, two,
and four for a unit stationed in Cambria
C. The areas listed above shall be known as Code 8 locations.
D. Med-Com may request an ambulance unit move into another service area
if they feel this will provide better coverage. If this occurs Med-Com will
provide that ambulance unit with a location to stage. This location shall be
known as the Code 11 location.
OL -
E. This move-up procedure may be altered by Med-Com if they feel that the
positioning of an ambulance, at an area other than the ones listed above,
would provide better ambulance coverage.
6.60.060 Ambulance rates. Page 1 of 1
Title 6 BUSINESS LICENSES AND REGULATIONS
Chapter 6.60 PREHOSPITAL EMERGENCY MEDICAL CARE AND TRANSPORT SERVICES*
6.60.060 Ambulance rates.
(a)Any ambulance service provider which operates within the unincorporated territory of the county
shall not charge any rate until that rate has first been approved by the board of supervisors through
inclusion of the rates in provider agreements approved by the county.
(b) All county ambulance service providers doing business within the unincorporated territory of the
county shall maintain a schedule of their current rates in each ambulance that they operate.
(c) This section shall not apply to services provided by any public entity responding within that public
entity's jurisdictional boundary. (Ord. 2629 § 1 (part), 1993)
http://www.sloclerkrecorder.org/CountyCode/_DATA/TITLE06/Chapter_6_60_PREHOS... 1/26/2005
6.60.070 Financial responsibility. Page 1 of 1
Title 6 BUSINESS LICENSES AND REGULATIONS
Chapter 6.60 PREHOSPITAL EMERGENCY MEDICAL CARE AND TRANSPORT SERVICES*
6.60.070 Financial responsibility.
As required by Title 13 of the California Code of Regulations Section 1106.2, no owner shall use any
ambulance, or permit any ambulance to be used,to transport passengers for hire without maintaining the
ability to respond in damages as required by Vehicle Code Section 16500. (Ord. 2629 § 1 (part), 1993)
http://www.sloclerkrecorder.org/CountyCode%DATA/TITLE06/Chapter_6_60_PREHOS... 1/26/2005
6.60.010 Definitions. Page 1 of 2
Title 6 BUSINESS LICENSES AND REGULATIONS
ChaQter 6.60 PREHOSPITAL EMERGENCY MEDICAL CARE AND TRANSPORT SERVICES*
6.60.010 Definitions.
As used in this chapter,the following words and phrases have been patterned after the meaning ascribed
in the National Association of EMS Physicians (NAEMSP) Medical Director's Handbook,hereafter
referred to as the "NAEMSP glossary." In particular, the following terms shall have the following
meaning:.
(1) "Ambulance" means a vehicle certified by the California Highway Patrol or other applicable state
authorities as meeting specifications for transporting and caring for patients. This term generally refers
to a wheeled vehicle, but may include boats,planes,helicopters and other specialized vehicles. A type I
ambulance consists of a truck cab-chassis with a modular body that allows for replacement of the chassis
and reuse of the modular body. A type II ambulance consists of a standard van-forward control-integral
cab-body unit. A type III ambulance is a specialty van with forward control and usually with the ability
to walk through from front.
(2) "Ambulance service area" means those ambulance service areas established within the county and
designated in individual county ambulance service provider agreements.
(3) "Ambulance service provider" means any private or public entity or person operating, owning or
controlling one or more ambulances, in a contractual agreement with the county of San Luis Obispo.
(4) "Board" means the board of supervisors of the county.
(5) "Central dispatch" means the San Luis Obispo County medical communication system(MED-COM)
dispatch point.
(6) "County" means the county of San Luis Obispo.
(7) "Dispatch time" means the interval from when a request for an ambulance is received by central
dispatch until the ambulance is notified.
(8) "Emergency call" means a request for assistance that activates the EMS system. It may come through
a variety of mechanisms: voice, regular telephone, 911 or radio.
(9) "Emergency rescue vehicle" means any privately or publicly owned motor vehicle, boat, aircraft,that
is specially constructed,modified, equipped or arranged, and operated,that would aid in life saving
activities in the event of a sudden, generally unexpected occurrence demanding immediate action.
(10) "EMT-D" means emergency medical technician-defibrillator; an EMT-I with additional training to
perform cardiac defibrillation on unconscious, pulseless and anemic patients,as defined by 22 California
Code of Regulations Section 100064.
(11) "EMT-I" means an emergency medical technician I as defined in Health and Safety Code Section
1797.80 and 22 California Code of Regulations Section 100063.
(12) "EMT-P" means emergency medical technician-paramedic; an EMT-A with additional training to
the full advanced life support level,as defined in Health and Safety Code Section 1797.84 and 22
California Code of Regulations Section 100138.
(13) "First responder" means the first individual to arrive at the scene certified to render medical care in
response to an emergency call.
(14) "Local EMS agency" means the county health department.
(15) "MED-COM" means the radio,telephone and dispatch system equipment that makes up the San
Luis Obispo County medical communications system.
(16) "Patient" means a wounded, injured, sick, invalid, convalescent, infirm or otherwise incapacitated
person requiring immediate medical attention and/or presenting a significant probability of requiring
medical care while being transported, as judged by the most highly medically qualified person at the
scene.
http://www.slocterkrecorder.org/CountyCode%DATA/TITLE06/Chapter_6_60_PREHOS... 1/26/2005
6.60.010 Definitions. Page 2 of 2
(17) "Remote area" means areas of the county which have a population density of nine persons or less
per square mile.
(18) Response code:
(A) "Code I" means an ambulance is to arrive at its destination at the earliest convenience.
(B) "Code II" means an ambulance is to proceed to its destination as rapidly as possible, obeying traffic
laws.
(C) "Code III" means an ambulance is authorized to use a red warning light and siren.
(19) "Response time" means the interval of time from ambulance notification until the ambulance is at
the scene.
(20) "Rural area" means all definable community areas of the county with a population of less than two
thousand five hundred and population density of ten to ninety nine persons per square mile.
(2 1) "Urban area" means all definable community areas of the county with a population of two thousand
five hundred to five hundred thousand and a population density of one hundred or more persons per
square mile. (Ord. 2629 § 1 (part), 1993)
http://www.slocler-krecorder.org/CourityCode%DATA/TITLE06/Chapter_6_60_PREHOS... 1/26/2005
6.60.020 County ambulance service provider agreement. Page 1 of 1
Title 6 BUSINESS LICENSES AND REGULATIONS
Charter 6.60 PREHOSPITAL EMERGENCY MEDICAL CARE AND TRANSPORT SERVICES*
6.60.020 County ambulance service provider agreement.
No individual,partnership, corporation or other entity shall operate, conduct, advertise or otherwise be
engaged in the business or service of the transportation of patients upon the street, or any public way or
place within the county, unless the county,through the board of supervisors, has executed a written
county ambulance service provider agreement with the individual,partnership,corporation, or other
entity. An ambulance operated by an agency of the United States or by the state shall not be required to
have such an agreement.
(1)The county ambulance service provider agreements with private providers shall provide for some
method of ensuring that in the event the provider ceases to perform the agreement for any reason
(including insolvency, bankruptcy, voluntary or involuntary dissolution of the business)the ambulances
and operating equipment used by the provider in carrying out the agreement will be available for use by
the county, or another private provider operating under agreement with the county, free of any legal
encumbrances. The provisions may take the form of county ownership with lease-back arrangements or
some other method, as recommended by the ambulance performance/operations committee.
(2) The agreements shall address other areas of operation and performance, including,but not limited to,
coverage requirements,minimum response time standards, staffing and certification requirements,
review of financial and other records, data collection and reporting requirements, system interaction and
rates.
(3)The agreements will be developed by the ambulance operations/performance review committee
before submission to the board of supervisors for approval on behalf of the county.
(4)During the term of any agreement,proponents of any additional provider service in any of the
assigned ambulance service areas shall have the burden of demonstrating that the public health, safety
and welfare require the additional service. (Ord. 2629 § 1 (part), 1993)
http://www.sloclerkrecorder.org/CountyCode/_DATA/TITLE06/Chapter_6_60 PREHOS... 1/26/2005