Critics rap ambulance changes.

Byline: Joe Mosley The Register-Guard

Eugene Fire Chief Tom Tallon has described it as fixing a broken and outdated system, but critics of a recent ambulance service redesign are wondering aloud whether things work as well now as before the system was fixed.

Springfield Fire Chief Dennis Murphy, for instance, points out that the city managers of Eugene and Springfield got together a couple of years ago to acknowledge a seamless ambulance service operated between the two cities for 20 years and to pledge even greater cooperation in the future.

"Now here we are, and (Eugene fire officials) have notified us we are going to be (dropped) out of two agreements we have with them, and they've instituted hard boundaries," Murphy says.

After a two-year study of Eugene's emergency medical services, Tallon initiated a sweeping redesign Aug. 1, in an attempt to save money, raise ambulance-related revenue and increase efficiency.

Changes included the "hard boundaries" policy, under which Eugene has laid claim to all medical calls within its ambulance service district - even if an ambulance from Springfield to the east or Lane Rural Fire District to the northwest happens to be closer.

The move reversed a long-standing "automatic aid" agreement under which Eugene and Springfield ambulances operated almost interchangeably within the two cities. In 1985, for instance, the Eugene and Springfield departments were jointly named the Paramedic Service of the Year by the National Emergency Medical Technician Association.

Doctor airs concern

"The old system worked well for 22 years," says one local emergency room doctor who asked not to be identified out of concern for his ongoing working relationship with Eugene fire officials.

"There is one case in 25 where these things make a big difference," the doctor says. "But it's really a significant change if political boundaries now have to make such a big difference."

Criticism both outside the Eugene department and by unions representing firefighters and paramedics from both cities led to a series of discussions between the two fire chiefs this week.

Murphy now says the Eugene department has backed away somewhat from its hard boundaries, though he remains concerned with Eugene plans to begin providing its own ambulance billing service and Firemed ambulance subscription plan - services that have long been handled by the Springfield department.

Eugene fire spokesman Glen Potter confirms that a narrow category of ambulance calls - "those rare calls when immediate transport to a hospital will have an effect on a patient outcome" - will soon be exempted from the hard boundaries policy.

Emergency rating system

All requests for emergency medical service are categorized on an "a" through "e" scale by dispatchers. Nearby ambulances from outside jurisdictions will no longer be prevented from responding to the most serious calls at the "e" end of the spectrum - known as "echo" calls.

"We're prepared to provide reassurance to the community that it will not occur," Potter says. "If there's an 'echo' call, the nearest available transport unit will be dispatched - and we are talking about 10 to 12 calls citywide in a year that may meet those 'echo' criteria."

Even after that limited agreement, though, there remains some disagreement over the range of medical calls that fall within the 'echo' designation.

Potter says the amended hard boundary policy will ensure that Eugene or other ambulances will be dispatched "on the basis of whether it is or is not a critical life threat."

Eugene firefighter/paramedic Linn Burch, who is one of five paramedics from the Eugene and Springfield departments who do a weekly review of all emergency medical calls dispatched in central Lane County, says the "echo" designation encompasses many but not all life-threatening situations.

Anytime a patient's breathing is compromised, Burch says, the call is classified as an "echo." That could be anything from a choking baby to someone in cardiac arrest.

But unless breathing is impaired, most trauma calls - whether a motor vehicle accident or a fall injury - do not meet the "echo" criteria.

"It's great we're raising the hard boundary for (echo calls)," Burch says. "But some of the calls that are most time-critical ... where we need to have someone in the (hospital) operating room quickly, those will never be dispatched as an 'echo' response."

The union perspective

Gary Nauta, president of the Eugene Firefighters Association, says the Eugene and Springfield chiefs need to continue talking until they arrive at a "cost-neutral" means of guaranteeing that the closest available ambulances will be sent to all emergency calls.

"I believe this is definitely a step in the right direction, but we need to continue to have more dialogue," Nauta says. "From the union perspective, we want to provide the very best service to the community that we can, and this hard boundary policy is not accomplishing that."

The hard boundary issue has become the lightning rod of Tallon's sweeping redesign, but a departmental report on the redesign describes the policy as just one of several interrelated changes that have been made to shore up sagging revenue from ambulance services while restructuring fire and medic crews for optimum efficiency.

City has the authority

And other city, county and state documents indicate the Eugene department has acted within its authority in making the changes.

"It's very common to have those boundary issues - I wouldn't say it's an exception, in any way, shape or form," says Liz Morgan, ambulance program representative for the state Department of Human Services' Emergency Medical Services Division.

Lane County Health and Human Services Director Rob Rockstroh, who is charged with administering all eight ambulance service districts within the county, acknowledges that the decision is probably Eugene's to make.

But after serving two tours of duty in Vietnam, Rockstroh subscribes to the theory that life-or-death patients have the greatest chance of survival when top-flight emergency care is administered immediately, followed by quick transportation to a higher level of care - whether a field hospital or an emergency room.

"The huge difference in life-saving (in Vietnam) was the time," he says. "So if you tell me two or three minutes doesn't make a difference, I'm just going to look at you like you're nuts.

"Our common-sense argument is, speed is of the essence," Rockstroh says.

Jurisdiction over ambulance calls have become an issue largely because of the money involved. Emergency medical service is a self-supporting function within both the Eugene and Springfield fire departments, and each ambulance ride to a hospital costs the patient more than $700 or more.

The revenue stream became even more critical to the Eugene department after the Lane County Board of Commissioners awarded an ambulance service district to the Lane Rural Fire District in November 2001.

The new district - which stretches from the Irving area near Santa Clara to the communities of Monroe and Harrisburg in the north and to the Low Pass area along Highway 36 to the west - was carved from the district that had been served by Eugene medics since 1981.

The reduction of their own service district caused Eugene fire officials to look at cost-savings and efficiency measures so that staffing of the city's nine fire stations - including four ambulance crews - could remain at or near traditional levels.

Changes cut revenue

Lane Rural's new service district is expected to eventually siphon away as much as $500,000 per year from the Eugene district. And regional changes in the federal Medicare system's reimbursement structure for recipients' ambulance calls will likely carve another $750,000 from Eugene's annual emergency services budget by July 2005.

"Eugene Fire & EMS must find ways to increase the flexibility of the EMS system, along with ways to reduce operating costs and/or find new revenue sources using existing capacity and resources," last summer's report on Eugene's ambulance redesign concludes.

For the current fiscal year, which ends June 30, the number of patients transported in Eugene ambulances is projected to drop to about 9,610 from the 9,850 who were transported in the previous year.

A combination of reduced transport numbers and a less-favorable Medicare fee schedule is causing the department's receipts from ambulance calls to drop by about $450,000 from the $6.2 million collected in the fiscal year that ended June 30.

The fire department's ambulance fund received a $250,000 transfer from the city's general fund this year to help offset the other revenue decreases.

And while the department will not undergo any budget reductions this year, despite a citywide deficit of $1.8 million, the infusion from Eugene's general fund will not be extended into the fiscal year that begins July 1.

"That (one-time transfer) was to help with the transition - to figure out what we're going to do and how we're going to do it," says Dee Ann Hardt, the city's finance and management services director.

Tallon's ambulance redesign plan takes it from there.

The hard boundaries policy is expected to generate some additional revenue for the department, although last summer's redesign report offered no estimates on the amount, and fire officials remain unsure of the impact.

Other changes

A few other changes instituted as part of the restructuring are also expected to bring some savings.

Staffing of the city's Bailey Hill Fire Station - one of the four stations at which ambulances are on duty - was converted to a new "combination crew" of three firefighters cross-trained as paramedics, who can respond to fire calls in a fire engine and to medical calls in an ambulance.

Previously, the station - like the other three at which ambulances are on duty - was staffed with a three-person fire engine crew and a two-person ambulance crew.

Tallon also initiated a "single-role" ambulance crew stationed along with a traditional ambulance crew at the department's Valley River Fire Station.

Members of the new, single-role crew are trained only as paramedics, rather than cross-trained to also serve as firefighters, and work eight-hour shifts instead of the traditional 24-hour shifts.

The single-role crews allow the department to beef up its ambulance coverage during the busy hours of 3 p.m. to 8 p.m., and to thin the ranks somewhat when demand is lighter from 11 p.m. to 8 a.m.

The combination crew and single-role crews, when taken together, are expected to save the department as much as $200,000 per year.

Meanwhile, the city has increased the cost of its Firemed ambulance subscription memberships by $6 to $45 per year, and is working with the Springfield and Lane Rural departments to recoup some of the costs of emergency medical dispatching that are now borne by the Eugene department alone.

Tallon has maintained that the changes, when taken as a whole, will actually increase the level of service within Eugene's ambulance service area while increasing revenue and reducing costs.

Changes under fire

Critics question both the effectiveness of the service changes and the amount of savings, with Nauta - the union president - maintaining in a recent letter to city councilors that, "Although the budget is complicated, it is not all that difficult to raise serious questions about where, in truth, the savings are."

He contends that the changes will result in the loss of several firefighter positions, increase the workload for night-duty firefighter/paramedics and result in a "much more transient work force" of employees working the less-desirable eight-hour shifts.

And the emergency room doctor who asked not to be named wonders if any savings can be realized in the Eugene department without consideration of how changes will affect operations and finances in neighboring ambulance districts.

For instance, the hard boundaries policy reduces the number of medical runs traditionally made by Springfield ambulances, putting pressure on the Springfield department to change its policies to make up for lost revenue.

"They don't seem to realize that if they cut in one place, the party on the other side of the river is just going to cut someplace else," the doctor says.

GLOSSARY OF EMERGENCY SERVICES TERMS

Hard boundary: Eugene Fire Department policy requiring that a Eugene ambulance be dispatched to calls within the city's ambulance service area. Only when a Eugene ambulance is not available may a unit from neighboring Springfield or Lane Rural fire departments may be dispatched.

Automatic mutual aid: The closest ambulance is sent to a call regardless of jurisdictional boundaries. Springfield and Lane Rural departments operate under this policy.

Ambulance service area: Geographic region served by an ambulance provider. Eugene, Springfield and Lane Rural departments cover central Lane County from Monroe to Creswell, and from Triangle Lake almost to Westfir.

Emergency medical technician: A first aid professional certified at any of three levels - EMT-basic, EMT-intermediate and EMT-paramedic.

Paramedic: The highest level of emergency medical technician training. A paramedic is authorized to administer various life-saving or pain-reducing drugs, and to perform a range of prehospital medical procedures.

Response time: The amount of time that elapses from when a dispatcher directs an engine company or ambulance to a call until the first unit arrives.

Engine company: Fire engines, located at each fire station, that are staffed by a three firefighters. Eugene's new policy mandates that at least one must also be a paramedic. Engine companies typically are the first on the scene of a medical call and stabilize a patient until an ambulance arrives.

Ambulance or medic unit: Ambulances are stationed at four Eugene fire stations, two Springfield stations and one Lane Rural Fire District station. Each is staffed by two paramedics and equipped with a full line of life-saving drugs and apparatus. Ambulances provide advanced life support and transport patients to hospitals.

EUGENE AMBULANCE ACTIVITY

Fiscal year 2000: A total of 8,822 patients were transported, generating $5.1 million in revenue.

Fiscal year 2001: A total of 9,193 patients were transported, generating $6 million in revenue. Ambulance rates increased on July 1, 2000 - the first day of the 2001 fiscal year - to $695 per patient from $595.

Fiscal year 2002: A total of 9,850 patients were transported, generating $6.2 million in revenue.

Fiscal year 2003: A total of 9,610 patients are projected to be transported for the budget year that ends June 30, generating an estimated $5.75 million in revenue. Ambulance rates increased on July 1, 2002 - the first day of the 2003 fiscal year - to $730 per patient from $695.