City officials are examining Three Rivers Ambulance Authority after it made an emergency declaration this year, but an expert said Fort Wayne's system isn't the only one that needs an overhaul.
Nate Metz, president of the Indiana Emergency Medical Services Association, says all of Indiana's EMS systems, including Fort Wayne's, are outdated, and it's time to go back to the drawing board.
Most of the runs EMS departments go on are nonemergency calls, Metz said, and demands are different in today's world.
“The idea that an ambulance only gets paid when the wheels move is crazy – absolutely crazy,” he said. “Indiana is still sitting on an antiquated business model that no one else will touch.”
The city created the Three Rivers Ambulance Authority in 1983 to save taxpayer money. Before that, local residents had Fort Wayne EMS, which was a city division that operated emergency medical services.
Like other city departments such as police and fire, Fort Wayne EMS had a budget to pay its employees and operate the department. But while looking at raising taxes to support EMS services, former Mayor Win Moses Jr. heard about a way to operate EMS services where it wouldn't be a city department and wouldn't cost taxpayers a dime – the public utility model.
The public utility model was introduced by the late Jack Stout, an economist and EMS expert, in 1980 through a series of articles in the Journal of Emergency Medical Services. In a public utility model system, a government entity creates an ambulance authority that serves as a purchaser of emergency medical services from a contractor. Emergency services are paid with user fees.
Since the model was written into ordinance, no other ambulance companies can operate stretcher transports in the city. Gary Booher, executive director of Three Rivers Ambulance Authority, said it has been following the same rules since.
The Fort Wayne Fire Department proposed in 2016 taking over emergency medical services entirely, dissolving Three Rivers Ambulance Authority. Ron Schwartz, president of the authority's contractor PatientCare EMS Solutions, said then a change wasn't needed, in part because the city's contract includes a maximum run time of 81/2 minutes, which the authority “has never failed to meet in 33 years of existence.”
The state of the ambulance authority in 2021 is different. City Councilman Russ Jehl alerted the public in July that Three Rivers Ambulance Authority's board of directors had approved an emergency declaration without letting the council or public know. It was because the contractor had been out of compliance regarding run times since August 2020.
Public utility model
The public utility model makes the ambulance authority a “competitive monopoly,” Booher said, because the authority is always looking for the highest efficiency at the lowest cost when it asks for bids.
The ambulance authority has a board that is made up of four mayoral appointees, four appointed by the county commissioners and the chairman of the EMS Foundation medical control board. The authority handles the billing, and the contractor handles operations, from hiring employees to maintaining its ambulances.
Even though the ambulances bear the TRAA name, the ambulance authority doesn't own them. The ambulances are owned by PatientCare EMS Solutions, a company based in Tyler, Texas, that has been the city's contractor since 2009.
PatientCare operates emergency medical services in six other communities across the country. The ambulance service is known as whatever name the community wants it to be called, such as Sunstar Paramedics in Pinellas County, Florida.
The ambulance authority has employed four contractors in its 38-year history, Booher said. Contractors can be a private company like PatientCare or other types of agencies, such as the city's fire department.
Fort Wayne EMS was funded primarily by taxpayer money, but Three Rivers ambulance services are funded in full through users' fees, whether they come from patients, private insurance companies or Medicaid or Medicare.
Some ambulance authorities receive tax money, but that wasn't part of the 1983 agreement.
“Whatever the rules are, we will work within the rules,” Booher said.
Even if an ambulance is running behind, Fort Wayne firefighters with advanced life support training are expected to be there in a few minutes, Fire Chief Eric Lahey said.
Fort Wayne firefighters were only required to have basic life support training until about five years ago, he said. Lahey would not comment on anything directly regarding the ambulance authority since he is a board member, but he shared information about firefighters' training with The Journal Gazette.
It worked against the department when it proposed taking over emergency medical services in 2016. Lahey suggested the change because it would keep the annual $900,000 budget in Fort Wayne rather than going to a company in Texas.
Schwartz said the change could cost lives since the fire departments' employees weren't trained to the level of paramedics. He added that the fire department wouldn't be permitted to go for the ambulance authority's contract because of the lack of training.
After entering an agreement with the ambulance authority, all Fort Wayne firefighters hired since 2016 are now trained as paramedics.
Fire stations are placed strategically around the city so they can make three-minute response times, making them ideal first responders. Firefighters can jump aboard an ambulance if a paramedic isn't present and paramedic-level care is suddenly required.
Even with ambulance staffing issues, Lahey said, the level of emergency care Fort Wayne residents receive has not changed.
“We are all committed to saving lives in the communities in which we serve,” he said.
Holding it accountable
One of the functions the ambulance authority board serves is to make sure the contractor is in compliance with the agreement struck 11 years ago when PatientCare became the city's contractor. One measure is that 90% of calls are required to have medics arrive in the 81/2-minute window in the agreement.
PatientCare has been out of compliance since August, and it has been fined more than $575,000 since.
Mike Bureau, the ambulance authority's operations director, said it continues to hemorrhage employees.
The shortage of paramedics and emergency medical technicians is a national problem, Booher explained, and the board has taken steps, such as switching to a system in which paramedics with advanced life support are only sent on life-threatening calls. The two-tiered system is expected to alleviate the need for mandatory overtime.
The board's only other option, Booher said, is to find the contractor in default.
“But where does default leave us?” he said. “It just shifts the problem.”
No other city or county in Indiana has emergency management services through a public utility model, Booher said. It's a rare model used around the country today.
Several agencies that were known for using the model are now what Booher calls “ex-public utility models.” The ambulance authority still exists, but it works as its own contractor.
That's the case for emergency medical services in Richmond, Virginia; Oklahoma City and Tulsa, Oklahoma; Reno and Washoe County, Nevada; Fort Worth, Texas; and Little Rock, Arkansas.
The example Booher provided of another system using the public utility model is Pinellas County, Florida, since there aren't any others in the state. Its contractor is also PatientCare.
Booher said many public utility systems receive some type of subsidy, even if it isn't cash. In some cities, the city buys the ambulances, which reduces the costs paid to the contractor. Three Rivers Ambulance Authority hasn't asked for a subsidy in the past, but Booher told the council in July it might see a request in the future.
Emergency medical services are done differently depending on the city. Many, such as the Muncie department, use a two-tiered system that reserves paramedics for calls requiring advanced life support training, similar to the one Three Rivers is currently implementing.
In Indianapolis, there are at least six emergency medical services companies competing. South Bend has the biggest fire department-based emergency medical services system in northern Indiana, according to its website.
A statewide issue
Many of the rules for Indiana's emergency medical services were created in the 1970s, Metz said, and demands for agencies have changed since then.
“When you call 911, an ambulance arrives,” he said.
But that isn't the reality of providing emergency medical services in 2021. Metz said a high majority of calls are non-emergency runs, and much of medics' time on calls is spent with patients with chronic illnesses.
Metz imagines a world of ambulance agencies working with nonprofits, grants and other funding sources that aren't attached to Medicaid and Medicare. Maybe then, the wages for medics could compete with unskilled jobs created by private companies, he said.
Calls recently have been up 44% across the state, Metz said, and that is being handled by short staffs and medics working mandatory overtime.
Metz said he has been bringing awareness to the issue for about eight years, and he hasn't seen much change.
“Just know that the ones who are answering the calls, they are the ones deciding to stay in this,” he said. “They are tired, they are overworked and what we need from the community is we need support and patience right now more than ever.”
A previous online version of this story misstated the training required for Fort Wayne firefighters. All Fort Wayne firefighters hired since 2016 are now trained as paramedics.