News

EMS Consultant Advises Ky. Counties: Give Up Dispatchers, Change Retirement Plan

Melinda J. Overstreet

04/30/2016

April 30--GLASGOW -- After nearly six months of reviewing most every aspect of the ambulance service for Barren and Metcalfe counties, the consultant hired by the service's board discussed Wednesday his findings, as presented in a 60-plus page document.

The initial summary addressed a range of issues, and 40 recommendations were listed in conclusion, and David Carter, a senior associate with Missouri-based Fitch & Associates, touched on most of them in his remarks to the board. A few of those include:

--Benefit expenses are 46.5 percent of wages, which is 15 to 20 percent higher than similar systems, with retirement benefits as a major contributor. "I've never seen benefits that expensive," Carter said. He recommended, if the organization's bylaws permit it, moving new employees to a 401k system rather than the state retirement system existing employees have.

If the bylaws don't allow that, the board should revisit the bylaws, he said. Actually, he suggested doing that, regardless, to set up a new version of a "standalone" organization and a board that would provide more liability distance from the entities included in the interlocal agreement that started the service.

--"The sharing of staff with the 911 center is complicated ...," it says. The recommendation was to transfer the dispatch staff who are employees of the ambulance service to the 911 center, the direct employees of which are city employees, and contract with the 911 center to provide dispatch services for the ambulance service. He also recommended that regardless of the time or day —because it's handled differently "after hours" than during normal business hours—all calls for service should be handled through the 911 center. "Ambulance billing starts from when the phone rings," Carter said, and he emphasized that key elements of information need to be captured from the outset. Specific technological suggestions for dispatching were also included in the report.

--In addition to forming the standalone organization, Barren-Metcalfe County Emergency Medical Services should should create a foundation -- a separate nonprofit entity with a separate board of directors -- for the sole purpose of fundraising to help provide for long-term capital needs. He complimented the job that Mike Swift, the director of the service since day one, has done, but he said Swift is getting close to time for his retirement. He posed as one possibility hiring Swift to "live out his days" as the head of that foundation. The service should find seed money to establish the foundation, he said. Swift said after the meeting that Carter had come to him and asked whether he would consider doing that, and he had told him he would.

--Ambulance fleet age and mileage need to be addressed through a capital replacement plan. He suggested purchasing four ambulances over the coming two years. Three ambulances were listed in the written report as having more than 200,000 miles and another was almost at that mark; Carter said they should be replaced at 200,000 miles or within four or five years. On the one hand, he said, the service's cost per transport is relatively low, but he said that was probably largely due to equipment depreciation.

--Minimum staffing should be three units, with additional units during hours of peak demand, and the service should consider going to 12-hour shifts instead of the 24-hour shifts most have. The exception to that is one crew that only works a 10-hour peak-time shift. "If you've had a busy day, it's hard to stay awake, literally," Carter told the board. He had provided detailed charts on unit hour utilization -- the amount of time a unit is staffed, on duty, and prepared to respond to a call. In response to questions from board member and Barren County Magistrate Carl Dickerson, Carter said moving to 12-hour shifts probably wouldn't necessarily save the service any money, because it may need to add staff, but the staff on duty could be more efficiently utilized.

--Chute times -- the time it takes to get a unit rolling in response to a call -- are averaging 2 to 3 minutes, which he characterized as "rather long," when they should be approximately 1 minute, Carter said, so specific response time targets should be set and measured for urban and rural settings. He discussed other benchmarks of medical first response as well, such as on-scene arrival times, which vary from urban to rural areas. The best-practice goal time is just shy of 9 minutes within city limits of Glasgow, and just shy of 15 minutes for the rest of the service area.

--The headquarters building off East Main Street is in serious need of updating or replacement, as it has not been upgraded since it was constructed decades ago, and it was clear to him that things had had to be "rigged" and it needed work.

--Carter's report said he also performed a cursory review of the accounts receivable and billing processes, for which the service pays a separate contractor. He told the board it really needed to "dive into" why so many accounts were still in the system at 180 days past due, when typically, nothing will be collected on an account after 130 days.

Barren County Judge-Executive Micheal Hale, a member of the board, pressed Carter to prioritize his list of recommendations, to suggest what should come first. He said they'd been given "68 pages of problems" to address, and for the money it had spent for his work, he felt the recommendations should be ranked.

Board member and Glasgow City Councilman Freddie Norris said he liked that idea, and Carter agreed to do that, but not on the spot. He said he could probably have it done by the end of next week, but if not, it would be a few more weeks because he would be unavailable for a couple of weeks after that.

Carter did say that probably the top item should be working on the benefits cost issue.

"That's really killing you right now," he said. "It's costing you."

The next item, he said, would be the seed money to start the foundation and getting it set up, because some capital improvements would be necessary.

Fitch's fee was $37,800 plus an estimated $4,000 for travel expenses; the board voted in late October to hire the company after receiving proposals from it and one other firm. The decision to hire someone came as the amount of the service's deficit, which is covered by Barren and Metcalfe counties, the City of Glasgow and T.J. Samson Community Hospital, all of which have representation on the board, was climbing, and some members of those respective governments questioned whether the organization was being managed as efficiently as possible.

Carter told the Glasgow Daily Times before the meeting that he had been a paramedic and then a nurse and got bachelor's and master's degrees in business.

"I've been managing EMS services and hospitals most of my life," he said.

Norris asked Carter how many services he knew of from his experience had a tax base for its funding. Metcalfe County pays its portion of the deficit through a special taxing district; the idea failed in Barren County when the service started and most government leaders have appeared loathe to bring it up for a vote again.

Carter said that probably a quarter to a third of them were tax funded, but some had a portion of a sales tax dedicated to them, while others were property-tax based, like in Metcalfe County. The rest work off the coffers of local governments, like in Barren County, he said.

Dickerson asked whether many were privately owned, and Carter said not many for-profit ambulance services are in rural areas, because they don't have the volume to support them that urban areas do.