HomeMy WebLinkAboutItem 5.2 County Paramedic Program (2) t !
590 - 3d
CITY OF DUBLIN
AGENDA STATEMENT
CITY COUNCIL MEETING DATE: April 23 , 1984
SUBJECT Written Communication from Mel Hing, County
Administrator re : County Paramedic Program
EXHIBITS ATTACHED Letter from Mel Hing dated April 13 , 1984
City of Dublin Resolution 39-83
Plan Establishing Paramedic Program as a Benefit
Assessment District-July 20 , 1983
RECOMMENDATION Notify County Administrator of Desired Paramedic
Service Level
FINANCIAL STATEMENT: Annual assessment of approximately $5 . 73-$8 . 11 per
year depending on service level option selected.
DESCRIPTION On August 8 , 1983 at their regular City Council
meeting the Dublin City Council adopted Resolution 39-83 consenting to the
inclusion of the City of Dublin in the formation of the County Service Area
for Paramedic Emegency Medical Service .
The County has been proceeding with the establishment of this District and
the attached correspondence related to this process has been received. The
County has developed service level options for cities participating in this
program. They have requested that the City advise them in writing of the
service model chosen, no later than April 27 , 1984 .
Background
In November of 1982 the voters of Alameda County approved a ballot measure
advising the Alameda County Board of Supervisors to establish Paramedic
Service through an assessment district . The measure indicated that the
assessment to property owners would not exceed $10 . 00 per year . In the City
of Dublin 78 percent of those voting favored the establishment of the County
Paramedic Program.
The specific details of the service were discussed and revised by local Fire
Chiefs, City Managers, and elected officials of the affected cities . The
initial program proposed by the County provided for two paramedics with each
ambulance. Some of the cities involved in the program felt that the
paramedic service would impact the provision of fire services and requested
that three staff persons be available with each ambulance unit . Therefore,
the County has established two service level options for cities
participating in the paramedic program.
The Program will also alter the City ' s future costs associated with
ambulance dry-runs . At the present time the City is billed directly for
these costs . During the first six months of 1983-84 the cost to the City
was approximately $180 . 00 per month . The formation of the assessment
district will eliminate this cost to the City. The funding will be derived
from the assessment district .
Service Level Options
The first option is based on the original concept of a two person paramedic
model . Also included would be the basic assessment to fund the Countywide
system costs associated with the Paramedic Program. The projected assess-
ment for this type of service,�would. by approximately $5 . 73 per assessment _
unit per year .
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COPIES TO:
ITEM NO. 5. z
The County has offered the option of having an ambulance staff with. two
paramedics and one EMT-I Driver . The additional cost of this type of
service would be an additional assesment of $2 . 38 per assessment unit per
year . If this option is selected the total assessment for paramedic
services would be approximately $8 . 11 per year . This represents a 41 . 5
percent increase over the cost of the first option.
Chief Phil Phillips of the Dublin San Ramon Services Distric Fire
Department , has indicated that historically there has not been a problem
with ambulance service impacting fire service in this area . Therefore, it
is not recommended that the paramedics provide an additional staff person on
the ambulance unit . Chief Phillips has indicated that DSRSD will monitor
paramedic services once the program is initiated, and will report to the
City Council if the program review shows a need for the higher level of
staffing . The Council would then have the option of reviewing the data and
determining whether an additional assessment is desirable at that time.
Chief Phillips has indicated that he will be present at the City Council
meeting to answer any additional questions .
Recommendation
It is recommended that the City Council direct staff to advise the County
Administrator that the City of Dublin requests the two person private
paramedic model . In addition, our response will indicate that the City of
Dublin would like an assurance that a paramedic unit will be stationed
within the Dublin City limits .
RECE
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COUNTY ADM INISTRATOPTY01: 0,
April 13, 1984
MEL HING STEPHEN A. HAMILL
COUNTY ADMINISTRATOR ASSISTANT COUNTY ADMINISTRATOR
Richard Ambrose, City Manager
City of Dublin
P.O. Box 2340
Dublin, CA 94568
Dear M Am' r
Subject: County Paramedic Program
As you are probably aware, the Alameda County Health Care Services Agency
(HCSA) is in the process of finalizing the implementation of the County
Paramedic Program whicn your city has elected to participate in and is
scheduled to begin July 1 , 1984. As part of that process, the HCSA is
coordinating a review of the proposals received from private companies and
cities interested in providing contract ambulance services in the County.
Prior to finalizing the contracts with providers, we would like a formal
response as to the service model you have chosen to be implemented in your
city. These models, as discussed in our numerous review sessions, include. a
two-person or three-person private paramedic service unit.
After the contracts are negotiated with providers, the HCSA will be finalizing
the program budget for 1984-85 and recommending that two assessment rates be
established by the Board of Supervisors that relate to the two-person private
and three-person private/city fire department paramedic service models. . It is
anticipated that the Board will establish the assessment rates in June, 1984
through a hearing process. Prior to any Board action, my office will provide
you with a copy of the HCSA' s recommended final program budget and assessment
rates for your information.
In the interim, I would appreciate it if you would provide a written response
on the service model chosen by your city to my office by April 27, 1984. If
you have any questions or require further information, please contact Adele
Fasano of my staff at 874-6252.
Very truly yours,
k�—HIN
coo ADMINISTRATOR
MH:AF: lb
cc: Carl Lester, HCSA
Ben Mathews, HCSA
Mayor Pete Snyder
6656C
1221 OAK STREET SUITE 555 OAKLAND, CALIFORNIA 94612 14151 874.6252
RESOLUTION NO. 39 - 83
A RESOLUTION OF THE CITY COUNCIL
OF THE CITY OF DUBLIN
------------------------------------------------------------ -
CONSENTING TO THE INCLUSION
OF THE TERRITORY OF THE CITY IN THE
FORMATION OF THE COUNTY SERVICE AREA
OF PARAMEDIC E2-'IERCEINCY MEDICAL SERVICES
ljvH='AS, the voters of each city and of the unincorporated area within
Alameda County at the November 2, 1982 General Election did approve County of
Alameda Measure C for the establishment of a county service area for the provision
of paramedic emergency medical services on a county-wide basis; and
bvTiEREAS, the Board of Supervisors of Alameda County is processing an
application to the Local Agency Formation Commission for the creation of the service
area; and
`vTT.REA.S, the Board of Supervisors has requested each city council to adopt a
resolution of consent for the inclusion of its territory in the formation of the
service area pursuant to section 25210.10a of the Government Code; and
jv=EAS, this City Council finds that the public health, safety, and welfare
of its constituency will be promoted by the service area;
NOW, ARE, BE IT RESOLVED, that the City Council of the City of Dublin
approves and consents to the inclusion of all of the incorporated territory of the
city in the formation of the county service area to be established for the provision
of paramedic emergency medical services; and
BE IT FUR= RESOLVED, the council directs the City Clerk to file certified
copies of this resolution with the Clerk of the Beard of Supervisors and with the
County Administrator.
PASSED, APPROVED AND ADOPTED this 8th day of August, 1983.
AYES: Councilmembers Burton, Hegarty, Jeffery & Mayor Snyder
NOES: None
ABSENT: Councilmember Moffatt
Mayor
ATTEST:
City Clerk
A PLAN FOR ESTABLISHMENT OF A COUNTYWIDE
PARAMEDIC EMERGENCY MEDICAL SERVICES PROGRAM AS A
SPECIAL BENEFIT ASSESSMENT DISTRICT
Prepared By The
Alameda County Health Care Services Agency
July 20, 1983
PREFACE AND EXECUTIVE SUMMARY
On November 2, 1982, the voters of Alameda County overwhelmingly approved a bal-
lot measure advising the County Board of Supervisors to establish a Countywide
Paramedic Emergency Medical Services Benefit Assessment District. This Plan will
provide for the implementation of the Countywide Paramedic Emergency Medical Ser-
vices (EMS) Program, in accordance with the regulations and standards established
by the State and the County, will improve the County's EMS System established in
1976/77 and will recognize the special needs and interests of the municipalities
in the County.
The proposed budget for funding assumes that all fourteen municipalities would
become participants in the special service district and that a basic benefit
assessment will be established to fund the Countywide system costs for adminis-
tering and supporting paramedic emergency ambulance service, including all County
costs related to the responsibilities which are mandated to the County by State
EMS Laws.
This plan has been modified from earlier drafts to incorporate the recommenda-
tions and interests of the municipalities which are:
-- That there will be two levels of assessment established: (1 ) the basic
assessment to fund the Countywide system costs and the costs of the County
recommended two-person paramedic unit model and (2) a supplemental
assessment to fund the added cost of the three-person unit and fire
department operated services in those areas so opting.
-- That three-person staffed paramedic units will be provided for those
municipalities requesting this level of service with the higher costs
being funded by a supplemental assessment.
-- That municipalities operating or considering operating fire department
emergency ambulance service will have the option to upgrade the services
to the paramedic level and fund any increased costs by requesting that the
supplemental assessment be established.
-- That the customary two-person staffed paramedic units will be provided
under County contract for cities whose fire departments will be able to
assist the paramedics at the scene and during transport when such assist-
ance is beneficial to patient care.
The proposed basic program budget is based on the annual projected costs which
would include $1 ,162,995 of current EMS program costs, projected new program
costs of $1 ,365,500, and a 10 percent contingency fund added for a total program
cost of $2,781 ,345. The basic annual assessment for each benefit assessment unit
would be $5.73. The estimated supplemental assessment for the three-person
paramedic unit is estimated at $2.38. Cities opting to provide fire department
paramedic ambulance service would have the option to request the Board to estab-
lish the supplemental assessment for their respective areas if needed to cover
the costs of the service.
The plan also recognizes the important service provided by the fire department
first-in response to medical emergencies and recommends funding to provide
Emergency Medical Technician-I (EMT-I) training, certification, and recertifica-
tion for all firefighters in Alameda County. The plan and proposed budget also
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recognizes the essential services provided by designated ALS base hospitals which
provide the immediate medical direction to paramedics. Funds are budgeted to
allow some subsidy to ALS base hospitals to cover the costs not recovered by
patient charges.
The issues remaining which may require additional '*Consideration and which are
specific to city fire department operated paramedic. ambulance service are:
1 . the extent to which medical standards can be flexiblly applied to city
paramedic service with low emergency medical activity
2. whether the County's EMS administration costs would be different for a city
operated service area than for a private contract service area
This plan would upgrade the County's EMS System with the addition and availabil-
ity Countywide of "state of the art" prehospital advanced life support paramedic
care.
The Agency recommends:
1 . That the proposed program be presented to the Board of Supervisors and to
the Cities of Alameda County for implementation.
2. That funds generated by the benefit assessment be utilized to provide a
uniform level of paramedic service throughout the County, with the
necessary support services which are a County responsibility.
3. That Cities currently providing and those planning to provide emergency
ambulance service be given the option to participate in the assessment
district, providing that such ambulance service would deliver the same
improved level of prehospital care and that such service would meet all
medical standards established by the State and the County.
4. That upon determination to form the assessment district, all services to
be contracted should be selected through a Request for Proposal (RFP)
process, utilizing performance standards and functional service areas.
The Emergency Medical Care Committee of Alameda County should develop
recommendations on both performance standards and functional service
areas for approval by the Board of Supervisors.
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PUBLIC MANDATE
On November 2, 1982, the voters of Alameda County approved Measure C (79%) ad-
vising the Board of Supervisors to establish a countywide paramedic emergency
medical services program which will provide prehospital advanced life support to
victims in- response to emergency calls and to be financed by a benefit assessment
on real property within the county not to exceed ten dollars annually for each
benefit unit in accordance with the schedule of benefit units defined as a
guideline in Board Resolution No. 194046.
Advisory Measure C was based on a proposal developed by the Health Care Services
Agency and reviewed and recommended by the Emergency Medical Care Committee.
This preliminary proposal recommended that the emergency ambulance services pro-
vided under County contract could be upgraded to include paramedic advanced life
support prehospital care, and that the County cost of this EMS program could be
financed through a countywide benefit assessment of approximately $6.70 per
benefit unit. The projected costs included the current program costs and the new
costs associated with the paramedic program. These recommendations include the
recommendations from the Cities in Alameda County and revised cost estimate.
This plan reviews the current EMS System in Alameda County, the changes and
additions which will be required to provide countywide paramedic service, some
of the alternatives considered, and the Agency's recommended methodology for
implementing the countywide paramedic program.
LEGAL AUTHORITY
The County Services Act, Government Code Sections 25210 et. sea. provides that
the Board of Supervisors may create a county service area for emergency medical
services to include advanced life support paramedic services and finance the
service area with a benefit assessment. A city may be included in a county ser-
vice area by a majority vote of the city council .
California Health and Safety Code Emergency Medical Services and Emergency
Medical Care Personnel Act (Sections 1797 et. sea. ) authorizes the County to
establish an integrated emergency medical services program including ambulance
service, paramedics, and base hospital services. This legislation designates the
County Health Officer responsible for approving ALS programs, including training
and certification of personnel , and for assuring that such programs are effect-
ively organized, coordinated, and monitored to assure appropriate medical control
of the system. (Appendix A)
EXISTING EMERGENCY MEDICAL SERVICES SYSTEM PREHOSPITAL CARE IN ALAMEDA COUNTY
Alameda County has a countywide Emergency Medical Services (EMS) System which
provides coordinated response to medical emergencies in accordance with minimum
State Laws and Regulations. In September, 1982, a Pilot Paramedic Service was
initiated in selected areas of the County in accordance with a plan recommended
by the Emergency Medical Care Committee and authorized by the Board of
Supervisors. The prehospital care response components of the County EMS System
typically consist of the followi.ng sequence of events in response to a 119111'
medical emergency request:
1 . Emergency request received at any of the sixteen "911" public safety
answering points (PSAP) in Alameda County.
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2. The local public safety jurisdiction initiates a first-in response unit
to the scene to provide medical aid and concurrently requests the County
Central Medical Emergency Dispatch (ALCO-CMED) to dispatch an ambulance.
(In most instances, the first-in unit will be a fire department unit
with a response time capability of four minutes or less. )
3. ALCO-CMED initiates the requested ambulance from the appropriate EMS
Zone ambulance provider or the ambulance unit which is providing back-up
to the EMS Zone if the Zone Provider's units are already engaged.
The countywide average response time for the emergency ambulance is six
minutes. Ninety-five percent of the requests receive an ambulance
response within ten minutes or less.
4. The emergency medical technicians (EMT-IA) staffing the emergency ambu-
lance will assume responsibility for the patient, assess the patient's
condition, continue medical aid initiated by the first-in responder, and
prepare the patient for transport to the nearest appropriate hospital
emergency department. The patient will receive only basic first aid
until arrival at the hospital if the ambulance is staffed by EMT-IA
personnel .
An average of 13.4 minutes is spent at the scene by EMT-IA ambulance
personnel with patient assessment, first-aid, and preparation for
transport.
5. The patient is transported to the nearest appropriate hospital emergency
department for definitive medical care.
PARAMEDIC SERVICE
Upgrading prehospital emergency medical care with Emergency Medical Technician-
Paramedic (EMT-P) personnel enables more comprehensive assessment of the patient
and the initiation of definitive care at the scene and during transport to the
hospital . This assessment and treatment must be under the direction of base
hospital emergency physicians and mobile intensive care nurses certified by the
County Health Officer. This service is now being provided as a pilot program in
EMS Zones II, IV, V, and VII. (Oakland, Emeryville, Hayward, and the unincor-
porated area of Eden Township)
PROPOSAL FOR COUNTYWIDE PARAMEDIC SERVICE
The program for countywide paramedic service proposed by the Agency would:
1 . Provide for the three service model options which are:
-- paramedic ambulance staffed with two paramedics under contract with
private providers
-- paramedic ambulances- staffed with 2 paramedics and one EMT-I(A)
driver under contract with private providers
-- municipal fire department paramedic emergency ambulance service
under contract agreement between the municipality and the County
age 5
2. Ensure the availability of Advanced Life Support and Basic Life Support
Training Programs for prehospital care personnel .
3. Provide funding to train, certify, and recertify all firefighter per-
sonnel as Emergency Medical Technician-I and to equip first-in responder
vehicles with medical equipment appropriate for use by EMT-I trained
personnel . '
4. Expand and upgrade the specialized medical radio communications system
equipment and operations required for the paramedic program and provide
ALS radio equipment to all approved ALS providers.
5. Provide financial assistance to designated Advanced Life Support Base
Hospitals which provide medical direction and participate in continuing
education programs for prehospital care personnel.
6. Provide necessary staffing and support to the Agency's Emergency Medical
Services Program to assure effective medical direction, monitoring and
coordination of the EMS System.
FUNDING
The estimated annual budget for establishing a countywide EMS Benefit Assessment
District would include all new program costs resulting from the upgraded service
and the existing County EMS program costs, including ambulance subsidy. The
current dry run costs paid by cities or their equivalent would also be transfer-
red to the assessment district resulting in a savings to the cities which are
currently paying for dry runs.
Countywide EMS - Paramedic Program Costs (revised from previous proposal )
BUDGET SUMMARY:
FY 83/84 Budget Current EMS Program Cost $1,162,995
New Program Costs 1,365,500
Annual Basic Program Costs (First year) $2,528,495
Contingency Fund (10%) 285,140
Total Basic Program Budget, First Year $2,781,345
Total No. of Assessment Units
(reported by the Assessor) : 485, 119
Annual Basic Benefit Assessment: $2,781 ,345
475,TT7 _ $5.73
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BUDGET DETAIL:
Item Current ALS
BLS Program New Cost ALS % of
FY 83/84 Estimate Total Costs Total
Paramedic Emergency Ambulance
Subsidy $ 440,0001 $ 220,0002 $ 660,000 17%
Firefighter First Responder
EMT-I Training and Equipment 227,500 227,500 6%
Base Hospit�l Contracts
4 @ $35,000 140,000 140,000 4%
Central Medical Dispatch (CMED)
and Medical Communication
System Control 449, 100 100,000 549,100 14%
Paramedic Radio System Equipment
($900,000 -- 3 year procurement) 300,000 300,000 8%
Communications Equipment Main-
tenance and Amortized Replacement 25,895 100,000 125,895 3%
EMS Administration:
(Salaries, Benefits 248,000 160,000 408,000 11%
Services & Supplies)
Indirect County Cost 118,000 118,000 3%
TOTALS $1 ,162,995 $1,365,500 $2,528,495 67%
Contingency Fund
(10% of Total Cost) 252,850 6%
Total One Year Cost of County Recommended Program $2,781,345
Third Person, City-Operated Supplemental Cost Estimate 1,052, 048 27%
Estimated One Year Total Program Cost Funded by the
Benefit Assessment $3,833,393 100%
Basic Assessment: $2,781 ,345
Units = $5.73/year
Supplemental Assessment: (See page 7) $2.38/year
1Reduced July 1 , 1983 from $877;000
250 percent increase for higher personnel and equipment costs
Ie 7
COMPUTATION OF SUPPLEMENTAL ASSESSMENT: EXAMPLE ONLY
This computation is hypothetical and should not be interpreted as a committment
by any of the cities named.
No. Paramedic
Units Reauired
Service Area: 6
Oakland (can also cover Emeryville and
Piedmont)
San Leandro, Hayward, Union City, Newark,
and all unincoporated areas of Eden
Township (Castro Valley, San Lorenzo,
Ashland, etc. ) 6
Total Units 12
Cost of third person per unit $60,000
12 @ $60,000 = $720,000
Total No. Benefit Assessment Units in above defined service areas - 303,104
$720,000
303, 104 _ $2.38
The three-person unit supplemental assessment would provide the following
additional annual revenue to the cities operating Fire Department Services,
pro- viding these cities reouested that the supplemental assessment be added.
City Operated No. of Assessment
Fire Ambulance Units Rate Annual Revenue
Albany 6,866 2.38 $ 16,341
Berkeley 50, 177 2.38 119,421
Piedmont 3,963 2.38 9,431
ge 8
ESTIMATE OF ASSESSMENT UNITS (2/22/83)
Non-
Residential Residential
Jurisdiction Units Units Total Units
Alameda 25,559 2,237 27,796
Albany 5,998 868 6,866
Berkeley 43,583 6,594 50,177
Dublin 4,248 752 5,000
Emeryville 2,339 1 ,200 3,539
Fremont 47,001 3,764 50,765
Hayward 34,234 5,378 39,612
Livermore 16,449 1,530 17,979
Newark 10,116 967 11 ,083
Oakland 141 , 110 23,546 164,656
Piedmont 3,889 74 3,963
Pleasanton 11 ,450 1,084 12,534
San Leandro 27,084 4,241 31 ,325
Union City 12, 168 1,178 13,346
Unincorporated 40,708 5,770 46,478
TOTALS 425,936 59,183 485,119
COMMENTS ON PROPOSED BUDGET:
Paramedic Emergency Ambulance Service and Subsidy:
Service Models Options:
Paramedic ambulance service is proposed to be provided by one of three service
models as follows:
1. Private ambulance service contract: two-person paramedic staffing.
(Recommended model)
2. Private ambulance service contract: three-person staffing; two paramedics
and one EMT-I driver.
3. City Fire Department operated paramedic emergency ambulance: two person
paramedic staffing.
The two-person private ambulance model is the most cost effective and is the
model recommended by the County. This model is used to determine basic costs for
paramedic service and the amount of subsidy required. The three-person private
ambulance model and the municipal fire department model, while not recommended,
would be available at a higher assessment level in those areas so requesting.
Paramedic Ambulance Subsidy:
Paramedic ambulance subsidy is budgeted based on the County's current subsidy ,.
plus a 50 percent increase estimated for the higher costs of providing paramedic
service. The estimated subsidy includes the cost for dry runs which are cur-
rently paid by cities. Cities would no longer pay dry run costs under this plan.
age 9
A 50 percent increase in subsidy is budgeted as a new cost for ALS, related to
higher personnel and equipment costs. The actual cost of the subsidy will be
determined with the awarding of contracts following a Request for Proposal (RFP)
bidding process. The subsidy estimate is based upon the private contract service
model with the understanding that the major cost of the service will continue to
be paid by_ fees billed to patients and insurance.
For the higher cost of providing the three-person staffed paramedic unit or a
City Fire Department paramedic service, an additional subsidy will be determined
and funded by a supplemental assessment calculated at the cost of providing the
third person for the private ambulance. This same supplemental assessment would
be added at the request of cities operating Fire Department paramedic ambulance
service and would be additional revenue for these cities. The supplemental
assessment will be applied only to the cities and adjoining areas requesting a
higher cost service.
Fire Service Personnel EMT-I Training and Equipment:
This is recommended to improve emergency patient care provided by firefighter
personnel in their role as first-in responder. Although EMT-I training is not
required for fire service personnel , at least eight of the 17 fire departments
in Alameda County are now requiring EMT-I training. The amount budgeted for
EMT-I firefighter training would provide initial EMT-I training (96 hours) for
firefighters not currently trained and recertification training required
biannually for all firefighters. Budget estimates assume a cost of $300 per
student for the 96 hour course, if provided to on-duty personnel with a minimum
class of 12 students. Recertification training cost is estimated at $100 per
student. Fire departments would have the option of on-duty training or classes
scheduled for off-duty personnel where EMT-I incentive pay is provided.
Also included is funding to provide essential EMT-I medical equipment on each
fire vehicle used as a first-in response unit. (Portable suction and blood
pressure equipment, extrication and traction splints, etc. ) (Budget detail
Appendix B)
Base Hospital Subsidy:
The hospitals designated by the County as paramedic base hospitals are required
to provide on-line medical direction of paramedics, retrospective review of
paramedic services, and participate in continuing training programs for para-
medics, mobile intensive care nurses, and other prehospital personnel. County-
wide paramedic service will require that at least four (4) hospitals be designa-
ted as base hospitals. Three hospitals are currently designated base hospitals
under contract with the County. While there is presently no subsidy for this
hospital service, the workload is limited to the pilot program areas with only
two paramedic units functioning under each hospital. A "Base Hospital " does not
receive all the patients which receive paramedic prehospital care under direction
of the base hospital . Hence all costs related to base hospital responsibility
cannot be passed on as patient care fees. The subsidy is estimated at the cost
of one full time nursing position for four hospitals. Selection and designation
of base hospitals should be made. through a competitive Request for Proposal bid
process with consideration to EMS service areas, qualifications and experience,
and cost.
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Central Medical Dispatch
Central Medical Dispatch (ALCO-CMED) is the medical communications center and
link between the sixteen (16) "911 " answering points and the emergency ambulance
services. ALCO-CMED maintains status on all emergency ambulance units and
arranges for inter-zone backup when the resources within a zone are depleted.
This ability to provide back-up between zones allows for more effective use of
all ambulance units. CMED controls and coordinates the use of the paramedic
radio channels and coordinates EMS system activity with the city and county
public safety agencies for routine and multi-casualty or disaster operations.
CMED is also a principal source of EMS prehospital data. The increased radio
communications activity at CMED with countywide paramedic service will require
one additional radio dispatcher post position at an estimated cost of $100,000.
Paramedic Radio Equipment and Communications System Network:
There are eight (8) radio channels (paired radio frequencies) available for
paramedic - hospital voice and telemetry communication. These eight channels,
(radio frequencies) known as MEDCOM Channels, have been identified for all
paramedic operations throughout the nation: Because the use of these channels
throughout the Bay Area cannot be separated geographically, a nine county Bay
Area Communications Plan was developed in 1976/77 under the Association of Bay
Area Governments (ABAG) EMS Project. This plan provides for the use of these
channels in all nine Bay Area Counties by a coordinated momentary assignment of
channels. The Alameda County MEDCOM Radio System Network has been designed in
accordance with the Bay Area Plan. This MEDCOM radio network is centrally
operated by the County's Medical Dispatch at the Consolidated Dispatch Center
(ALCO-CMED) . The increased use of this radio system with countywide paramedic
service will require the expansion and improvement of the present network which
was designed and installed in 1977.
Because of the specific and complex nature of this communications system, it is
important that the County own and maintain all the medical system radio equip-
ment. This provides consistancy in the use and maintenance of this equipment.
The cost for the expansion and improvements to the radio network and the mobile
paramedic radios is estimated at $900,000. This one time cost is spread over
three years in the budget. The maintenance and equipment amortization cost will
provide for periodic replacement of this radio equipment thereafter.
EMS System Administration and Medical Control
The Health and Safety Code EMS Act mandates EMS regulatory authority and respon-
sibility to the County. Countywide paramedic service will increase the medical
control and monitoring workload for the EMS program requiring additional staff
and support services estimated at $160,000.
The County operated paramedic training program is being terminated in August,
1983. No funds are budgeted to pay or subsidize the cost of paramedic training.
In order to ensure that the training needs of the proposed program are satisfied,
alternatives to the County-operated program are being explored. The County's EMS
program administrative responsibilities are equally applicable throughout the
County and the related costs are, therefore, allocated as a uniform countywide
cost.
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EMS Administrative Activities
A. General Program Administration
1 . Designated local EMS Agency in accordance with Health and Safety Code
Chapter 1260
-- Overall EMS System planning, coordination, and evaluation
-- Staff support to the Emergency Medical Care Committee and related
subcommittees
-- EMS Public Information and Education
-- Participation in Regional EMS Coordination and Planning (Bay Area
Region)
-- Participation with State EMS - planning, evaluation, legislative and
regulatory process providing local government input and advocacy.
2. Develop and negotiate contracts and agreements for prehospital
emergency medical services; monitor contract compliance. (Contracts
with Cities and provider agencies. )
3. Develop, negotiate, and monitor agreements with hospitals related to
EMS Base and Receiving Hospital activities and responsibilities.
4. Develop and maintain operating procedure manual for EMS System
operations
and coordination.
5. Coordination of multiple agency roles and responsibility with EMS
System. Investigate incidents, resolve conflicts, and problems.
6. Fiscal administration --
-- Process and approve bills for contract payments (uncollectibles,
CMSP (MIA) claims, dry runs)
-- Administrative Budgeting and Budget monitoring.
B. Medical Direction and Control
1 . Personnel Training and Certification.
-- Approve and monitor prehospital care training programs (EMT-I,
EMT-P, MICN, Base Hospital Physicians)
-- Approve continuing education programs for certified ALS personnel .
-- Certify EMT-I, EMT-P, MICN, and base hospital physician personnel .
-- Monitor continuing education reauirements for EMT-P's and MICN's.
T •
Page 12
2. Develop maintain and evaluate medical standards, procedures, and treat-
ment protocols for prehospital emergency care to assure prospective,
immediate, and retrospective medical direction and control .
-- Medical advisory committees
-- Base hospital tape reviews and committees
-- Monitoring of services in the prehospital setting
-- Review and investigate problems, incidents, conflicts for resolution,
and improvement to the EMS system
-- Develop, organize, and participate in continuing education programs
for prehospital care personnel
-- Assist and participate in training programs for EMT-I, EMT-P, and
MICN personnel
C. EMS Disaster Preparedness Planning and Training
1 . Develop and maintain plans for response and medical management of
multi-casualty incidents.
2. Organize, coordinate, and monitor multi-casualty training exercises.
3. Plan and arrange for medical mutual aid and administrative support for
multicasualty and medical disaster assistance.
4. Coordinate Agency Health -- Medical Disaster Preparedness planning for
the County Health Officer
EMS Administration Budget Estimate for Countywide Paramedic Program
Current: (83/84 Budget Amounts)
Admin. Salaries and Benefits 5.0 FTE $155,000
Prehospital Care Coordinator 1 .0 FTE 30,000
Medical Director 0.25 FTE 18,500
$203,500
Services and Supplies 49,500
TOTAL $248,000 $248,000
New Program Requirements: (Increase in medical direction)
Medical Director 0.25 FTE $ 18,500
Prehospital Coordinators 3.0 FTE 81,000
Clerical 1 .0 FTE 18,000
Training and Testing Consultants 20,000
Services and Supplies and Equipment 22,500
$160,000 160,000•
Total EMS Administration Cost - Countywide Program: $408,000
e 13
CONTINGENCY FUND
A contingency fund is budgeted, as allowable by the laws governing special
assessment districts. This contingency fund is budgeted at 10 percent of the
program budget and could be used for program expenditures only with a 4/5 vote
of the Board of Supervisors. If the contingency fund and other budget funds
are not expended during a fiscal year, such remai6ing funds would roll forward
into the next year. Should a surplus occur in excess of the allowable 10 per-
cent contingency, this surplus would be applied to the district budget and
could result in a reduced assessment in the following year. A contingency fund
is recommended since the program is new and contractual cost for ambulance,
hospital , and training subsidy are not known.
PARAMEDIC PROGRAM STANDARDS AND OPERATIONAL CONSIDERATIONS
The proposed paramedic program is based upon the premise that paramedic service
will be provided by the provider(s) of emergency ambulance service in accord-
ance with State and County requirements, and that fees for service will be
charged which will fund a major portion of the cost of the service. Funds
generated by the proposed benefit assessment district will cover any subsidies
needed to assure availability and quality, and the County costs of system
administration, coordination, monitoring, maintaining the radio communications
system, first-responder EMT-I training and equipment and other costs associated
with the Countywide EMS System.
Variation in costs associated with geographical and demographic differences
(i .e. , population density, call volume, and socioeconomic factors) may require
a variance in basic subsidy level which would be spread over the countywide
base, since an objective of the assessment district is to provide a uniform
level and availability of service. Such variation, however, should be cost
effective in comparison to other similar geographical areas of the county.
Municipalities opting to provide paramedic emergency ambulance service would
be included in the assessment district under similar agreements, standards and
operational requirements that are established for private ambulance contract-
ors. Any higher costs resulting from a municipal operation would be identified
as a supplemental assessment for the service area.
LEGAL REQUIREMENTS AND STANDARDS FOR ADVANCED LIFE SUPPORT PARAMEDIC PROGRAMS
California Health and Safety Code authorizes the County to approve paramedic
programs and designates the County Health Officer responsible for certifying
paramedic personnel and for establishing and maintaining medical control of
paramedic programs. The following standards are applicable to any potential
provider of paramedic service and have direct bearing on the cost of providing
paramedic service:
Training: A prerequisite for paramedic training is EMT-I
certification and one year of experience.
The County approved paramedic training program
® requires a minimum of 850 hours with most students
averaging 1,000 hours.
,z 14
Paramedic certification requirements include a
minimum of 80 on-duty hours per month and an
approved plan to ensure that all certified para-
medics have adequate experience to maintain ALS
skills.
Continuing education is required to maintain cer-
tification. (A minimum of 18 hours for each six
month period. )
Operational :
Response time: The paramedic ambulance shall be able to respond
to 95 percent of requests in the service area
within ten (10) minutes from the time of dispatch.
Staffing: Paramedic units shall be staffed with two
certified paramedics (EMT-P). One paramedic takes
primary responsibility for patient care, the other
paramedic handles radio communication with the
base hospital , medical equipment and medications,
and assists the patient care paramedic.
Transport Capability: Paramedic teams must have the capability to
transport the patient. This is essential for
critical trauma.
Skills Maintenance: Paramedic personnel require continuous experience
to maintain competency with advanced life support
skills. Skills maintenance is best achieved by
insuring that paramedic personnel assignments
provide regular and frequent patient care.
ALAMEDA COUNTY EMERGENCY MEDICAL SERVICE PREHOSPITAL BASELINE DATA
The following data base is used for the purpose of developing cost comparison
estimates for County emergency ambulance paramedic service.
The Alameda County EMS System currently responds to approximately 60,000 medical
emergency requests each year. In response to these requests, an average of 25
emergency ambulance units are available and required to provide the required
ten-minute response time. For purposes of comparison, 25 paramedic units are
used as an optimum number, however, a lesser number may be possible if service
areas are established to provide optimum utilization.
Based upon existing methods of receiving and screening medical emergency
requests, approximately 25 percent of the requests terminate in a dry run, with
no patient transport provided. The average number of transports per day per unit
based on 25 units would be 4.8; whereas a unit should be able to effectively
handle 8 transports.
Page 15
OPERATIONAL CONSIDERATIONS
Organization, Administration, and Medical Control :
Since the inception of prehospital advanced life support in 1968, paramedic ser-
vice has developed in California in two significa6tly different operational
modes: (1) the paramedic ambulance unit, and (2) the paramedic rescue unit. The
paramedic ambulance unit mode may be operated by a private or public ambulance
service, or by a public safety department (fire and police). The paramedic res-
cue unit mode is operated only by public safety services, most commonly fire
departments.
Both the ambulance and the rescue unit modes represent a specialized service
which usually restricts their availability to emergency medical response. The
exception would be those public safety rescue units which may also respond to
other emergencies handled by their agency. Also, both modes typically rely on
the first-in response unit, because the paramedic unit should serve a greater
geographical response area to achieve cost effective utilization.
The paramedic rescue unit mode requires the concurrent dispatch of an ambulance
to provide patient transport to the hospital . Hence, in a system using paramedic
rescue units usually three separate vehicles staffed by a total of five to eight
personnel will be dispatched to a medical emergency -- the first-in unit, the
paramedic rescue unit, and the ambulance.
In systems using the paramedic ambulance mode, the first-in unit will be dis-
patched, together with the paramedic ambulance. Some significant advantages to
the paramedic ambulance transport mode are:
1 . The paramedic team has the ability to transport the patient immediately
in instances where immediate transport is essential (required for trauma
injuries) .
2. The established method of payment (revenue) for prehospital paramedic
service is connected with the patient transport. This represents the
major source of revenue to cover the direct cost of providing the
service.
PARAMEDIC SERVICE OPTIONS
The minimum staffing standard for a paramedic unit is two certified EMT-P para-
medics. It is customary for first-responder personnel to assist paramedics with
patient care at the scene and to have a firefighter accompany the patient during
transport to the hospital if CPR or other critical procedures are being per-
formed. Because of a projected increase in time on the scene when advanced life
support is initiated (an average increase of eight minutes) many of the city fire
departments have expressed concern that the paramedic program will reduce their
overall emergency response capability and/or result in future increased costs
related to fire protection services. Some cities may wish to continue or initi-
ate new municipal fire department emergency ambuIance ..service at the paramedic
level . The above concerns, interests, and differences have resulted in planning
,e 16
for three service modes for the delivery of paramedic emergency prehospital care
and ambulance service. The three modes are:
1 . Paramedic ambulance service with two-person paramedic staffing -- provided
under contract by private ambulance providers.
2. Paramedic ambulance service with three-person paramedic staffing -- two cer-
tified paramedics and one EMT-I (A) driver/assistant provided under contract
by private ambulance providers.
3. Fire department operated paramedic emergency ambulance service operated by a
minimum of two certified EMT-P paramedics.
The first option -- contracted private ambulance service with two-person para-
medic staffing -- is considered to be the most cost effective and is the option
recommended by the County. Both the three-person staffed paramedic unit and the
fire department operated service will require a greater amount of subsidy due to
the higher personnel costs. To provide funding for the higher costs of these
service models, a supplemental assessment would be calculated and added to the
basic assessment. The service areas receiving the higher cost service and
requiring a supplemental assessment would have to be geographically definable for
tax assessment and billing purposes as well as represent functional service areas
for the delivery of service.
Three-Person Paramedic Unit - Option
Three person staffing of each paramedic unit, while not recommended by the Coun-
ty, would satisfy the concern of many city fire departments that the paramedic
program will reduce their overall emergency response capability. would satisfy
this concern and allow for the prompt release of fire first-in responders in
almost all cases. Such a unit would be staffed with two certified paramedics
(EMT-P) and one driver-assistant with EMT-IA training (EMT-IA would be required
to qualify for the ambulance driver's license). This staffing would add an
additional cost of approximately $59,500 per unit per year estimated as follows:
3.5 EMT-IA positions for 24-hour staffing
3.5 x $17,000 = $59,500 ($60,000 is used for budget estimate)
A three-person paramedic unit would provided the following advantages to pre-
hospital patient care while greatly reducing, but not eliminating the EMS system
dependence on fire departments:
1 . First responder units would be returned to service upon arrival of the
paramedic unit.
2. During transport both paramedics would be available to attend the
patient, virtually eliminating the need for fire assistance during
transport.
3. The paramedics would always have a third team member to handle equip-
ment, assist with patient movement and lifting, and to drive the ambu-
lance. As a member of the team, the EMT-IA driver would be familiar
with the equipment and how to effectively assist the paramedics.
4
e 17
4. Ambulance companies could concentrate driver training on the EMT-IA
driver personnel .
The advantages of a three-person paramedic unit are obvious. The cost effect-
iveness, however may be difficult to justify. The direct benefit of the three-
person unit would be applicable to approximately 0 - 50 percent of emergency
patients who will require advanced life support prehospital care and the approx-
imately 5 percent of the emergency patients requiring two attendants during
transport. The added cost could not realistically be recovered by increased fees
and would, therefore, require a considerably high subsidy.
RECOMMENDATIONS FROM THE CITIES
The Alameda County City Managers, Fire Chiefs, and a Committee of the Mayors
Conference have reviewed the proposed program and recommended that the following
guidelines be incorporated in the formation of the benefit assessment district:
-- The response time for the ambulance shall not be more than ten minutes,
i .e. , the present County standard shall not be increased in time.
-- Operationally, all Fire Department personnel must be able to depart from
the scene upon arrival of the ambulance at the scene.
_ -- Operationally, Fire Department personnel shall not be required to assist
during single patient transport, unless the medical procedures absolutely
require more than two people (attendants) in the back of the ambulance,
which is projected at no more than 5 percent of the total transports.
-- The County shall fund EMT-I (FS) initial and recertification training.
The training scheduling shall be at the direction of the individual Fire
Departments. The County will not be required to fund related personnel
costs, e.g. , salary differentials or bonuses.
-- For those cities that provide their own ambulance service it is expected
they will have an opportunity to equitably participate to the fullest
extent they desire in the new ALS-EMS System.
City and Fire Service Recommendations Discussed:
The major concern expressed by the cities with implementation of paramedic ser-
vice is their expectation that when the paramedics provide patient care at the
scene, increased assistance will be required from t,oe fire team, increasing the
time on the scene and jeopardizing the emergency response capability of fire
departments which are operating at minimum staffing levels. The more costly
three-person staffed paramedic unit is proposed in response to this concern.
The Agency's proposed plan for paramedic service recognizes the importance of the
fire department first-in response and proposes that EMT-I training become a
standard throughout the County for firefighters. Included in the proposed budget
is funding for the cost of providing EMT-1 training for firefighters and for
equipping first-in fire department units with medical equipment needed by
firefighter EMT-I personnel . A uniformly higher level of training for first-in
responder will improve overall patient care.and will improve the effectiveness
of prehospital ALS.
Page 18
Cities currently providing fire department operated emergency ambulance service
would be provided the option to upgrade the emergency ambulance service from
EMT-I (A) to Paramedic (EMT-P) providing the paramedic service would meet the
State and County requirements and that any higher costs related to the service
would be covered by a supplemental assessment equal to that proposed for the
higher cost for the three-person staffed paramedic units.
The Agency's goal , in response to the November, 1982, vote, is to provide Alameda
County with a functional and cost effective medically directed prehospital care
system with advanced life support paramedic services.
The benefit assessment district proposed will work only with the participation
of the cities of Alameda County since the majority of EMS demand occurs in the
cities and a significant percent of the program costs are for the services
required to support the system. The alternative to a countywide coordinated and
tax supported system with paramedic service, would be the existing basic life
support service with the possibility of cities independently funding the higher
cost of paramedic service. The Agency must emphasize that paramedics do not
function independently. Only the County has the legal authority to authorize
paramedic service and the County through the County Health Officer has the
responsibility to assure that paramedic services are medically directed and in
compliance with the State and County standards.
The Emergency Medical Care Committee is in the process of reviewing the EMS
System standards and criteria for the EMS System including emergency ambulance
services and EMS service areas. This review and development of recommendations
to your Board could be completed by November 15, 1983, and the Agency could be
prepared to initiate a Request for Proposal process for paramedic emergency
ambulance service and base hospital services by December 31, 1983. This would
allow ample time to complete the process for an implementation date of July 1,
1984. This process would be applicable to all areas of the County to be served
by private provider contract services. The Agency anticipates that a fire de-
partment ambulance service would probably not be able to initiate paramedic
service earlier than January, 1985, to allow for the training of their fire-
fighter personnel .
SUMMARY AND RECOMMENDATIONS:
The Agency's proposed program would establish a Countywide paramedic service
which would provide advanced life support prehospital care within the existing
EMS System.
The Agency recommends:
1 . That the proposed program be presented to the Board of Supervisors and
to the Cities of Alameda County for implementation.
2. That funds generated by the benefit assessment be utilized to provide a
uniform level of paramedic service throughout the County, with the
necessary support services which are a County responsibility.
ge 19
3. That Cities currently providing and those planning to provide emergency
ambulance service be given the option to participate in the assessment
district, providing that such ambulance service would deliver the same
improved level of prehospital care and that such service would meet all
medical standards established by the State and the County.
4. That upon determination to form the assessment district, all services
to be contracted should be selected through a Request for Proposal (RFP)
process, utilizing performance standards and functional service areas.
The Emergency Medical Care Committee of Alameda County should develop
recommendations on both performance standards and functional service
areas for approval by the Board of Supervisors.
BHM/ms
07/20/83
APPENDEX A
COUNTY COUIN SEL
p p
C �•
DATE: March 15, 1983 ALAMEDA COUNTY HCSA
EMS ADMIN.
TO: Mel Hing, County Administrator
FROM: Richard J. Moore, County Counsel
SUBJECT: County Paramedic Program R E C E I V E 0
You have asked two questions concerning the County paramedic program, the first
of which was answered in my letter of January 31, 1983.
The second question is whether a city has the authority to establish its own para-
medic program and to levy special assessments to finance it.
Speaking generally, a city has "home rule" powers which enable it to undertake any
program the city deems beneficial for its citizens. However, under the preemption
doctrine a city may not so act where the state has "occupied the field" in a matter of
statewide interest. In order to determine whether preemption applies, it is necessary to
review the particular statute. Again speaking generally, if the legislation deals with a
subject which may reasonably be considered of statewide importance, or which arguably
requires action in a geographical area greater than any particular city, and if the
legislation indicates an intention to preclude city intervention, then preemption exists
and a city may not act in the area "occupied" by the state.
In this case, the legislation clearly indicates an intention to preclude city action.
Moreover, the geographical area of concern is greater than any particular city. The
Emergency Medical Services System and the Prehospital Emergency Medical Care
Personnel Act- was added in 1980, Health and Safety Code 51797, et seq. Section 1797.1
provides:
The Legislature finds and declares that it is the intent of this Act to
provide the state with a statewide system for emergency medical services
by establishing within the Health and Welfare Agency the Emergency
Medical Service Authority, which is responsible for the coordination and
integration of all state activities concerning emergency medical services.
Section 1797.2 provides:
It is the intent of the Legislature to maintain and promote the
development of EMT-P paramedic programs where appropriate throughout
the state and initiate EMT-II limited advance life-support programs only
where geography, population density, and resources would not make the
establishment of a paramedic program feasible.
Mel Hing
March 15, 1983
Page Two
It is thus clear that the state intends to act on a statewide basis on a problem which the
Legislature defines as one of statewide interest. This is typical language which the
courts have said indicates an intention to occupy the field. Section 1797.94 provides:
"Local EMS Agency" means the agency, department, or office having
primary responsibility for administration of emergency medical services in a
county and which is designated pursuant to Chapter 4 (commencing with
Section 1797.200).
Thus the state intends to designate the agency which is to implement the state's
program. Section 1797.200 provides:
Each county may develop an emergency medical services program.
Each county developing such a program shall designate a local EMS Agency
which shall be the county health department, an agency established and
operated by the county, an entity with which the county contracts for the
purposes of local emergency medical services administration, or a joint
powers agency created for the administration of emergency medical services
by agreement between counties or cities and counties pursuant to [joint
powers authority] . (emphasis added.)
Accordingly, the county is the state-designated agency to run this program. It is true
that if a city or fire district had, as of June 1, 1980, contracted for or provided
prehospital emergency medical services, the county is required to enter into a written
agreement with that city or fire district regarding the provision of those services.
(Section 1797.201) That section continues by providing, however, that in any case the
medical direction and management. of Ern emergency medical services system shall be
under the medical control of the medical director of the EMS Agency, discussed in
§1797.200 above.
It is our conclusion that unless a city or fire district comes within the provisions of
S1797.201, the county is the agency primarily responsible for the administration of this
program.
Assuming that a city comes within this exception which allows the city to maintain
the program, you then asked whether a city can levy special assessments to finance the
program.
Chartered cities have broad home rule powers to fashion new taxes, assessments,
and fees for revenue purposes. (Rivera v. City of Fresno (1971) 6 Cal.3d 132.) General
law cities rewire enabling statutes for those purposes. We are unaware of any statute
enabling a city to levy a benefit charge or a fee for an "extended service" against real
property, such as for paramedic services, like the one contained in the County Service
Area Law. (Gov't. Code 525210.77a). However, a city may finance such a service out of
its general fund, and may increase general revenues by the levy of certian non-property
taxes, (e.g., a business license tax), without two-thirds voter approval as required by
Article XIE A, section 4 of the California Constitution. (City and County of San
Francisco v. Farrell (1982) 32 Cal.3d 47.) Cities may also levy "special taxes" earmarked
for specific purposes with two-thirds voter approval. (Gov't. Code S50075.) Accordingly,
if a city is entitled to participate in the program, it appears likely that the city will have
the capacity to finance it.
RJM:BZ:bjh
APPENDIX 8
FIREFIGHTER FIRST RESPONDER EMT TRAINING
1500 - Firefighter personnel
• 60 percent require basic EMT training
Estimated cost/person $300.00
900 x $300.00 = $270,000
40 percent require recertification course
600 x $100.00 = 60,000
Estimated Training Cost first 2 years $330,000
Annual Cost $330,000/2 = $165,000
First responder EMT-I Equipment Cost
125 units @ $500 per unit = 62,000
First-Responder Total Annual Cost $227,500