Who Will Be There When You Call 911? Our Writer Plunges Into the World of For-Profit Ambulances.
From kickback schemes to political battles, Alameda County's emergency medical system has its share of issues.
Source: East Bay Express
At some point in your life, you may need to call a 911 ambulance for a serious medical emergency. Hopefully it will arrive quickly and transport you to a nearby hospital for care. But you may be concerned to learn that Alameda County's emergency ambulance system has its fair share of issues.
For instance, you could have to wait a while for your ambulance — in some cases up to 90 minutes. And while you wait, the responding medics also are waiting to catch a break, both literally and figuratively: Unlike their police and fire counterparts, for-profit emergency-medical technicians, also known as EMTs, only earn about the same as fast-food workers.
On top of this, the state ambulance lobby is pushing legislation to exempt paramedics and EMTs from meal breaks, and is working to hire cheaper replacement labor. And the industry is even considering putting people in Uber cars for those rides to the emergency room.
Higher up the ambulance-industry food chain, it's a world of big-money government contracts and political battles.
Meanwhile, Alameda County taxpayers are paying millions of dollars to help subsidize a Texas-based for-profit private ambulance company, and paying lawsuit settlements.
Earlier this year, for instance, Alameda County settled a federal "kickback schemes" lawsuit regarding Paramedics Plus, its provider for the last six years. Paramedics Plus also has been hemorrhaging money while doing business here, more than $48 million in the past six years.
"The system is so broken right now," Sean Burrows, president of the county firefighters' union, told the Express. "There are people who are being impacted negatively. The citizens are frustrated."
County health-care officials insist the situation isn't as bad as it might seem. But local firefighters want a chance to improve how emergency services are provided in Alameda County — yet they were shut out of the most recent bidding process.
Meanwhile, your ride in an ambulance could cost at least $2,100 — if you can get one.
When Will Your Ambulance Arrive?
Depending on where you call 911 in the East Bay, a host of different agencies could show up. The first medic on scene will likely arrive on an engine operated by your local public fire department. Outside of Berkeley, Alameda, Albany, and Piedmont — the four Alameda County cities whose fire departments handle its entire EMS response — an ambulance operated by Paramedics Plus, a for-profit company, will follow. It's the Paramedics Plus ambulance that will carry you to a nearby hospital.
But how long will it take for your lift to the hospital to arrive? Let's just say it varies.
"The system is so broken right now. There are people who are being impacted negatively. The citizens are frustrated."click to tweet
A 2014 report compiled by the county's Emergency Medical Services division indicates that ambulances typically arrive an average of seven minutes after firefighters. But that review excluded Oakland and Hayward, the largest and third-largest cities in the county, respectively, and both with high mortality rates.
Fire department dispatch records, however, indicate that response can be up to 90 minutes in some parts of the county, as ambulances are routinely unavailable.
When there isn't an ambulance to transport a person to the hospital, it's known as "level zero." Last December, Alameda County was at level zero 222 times over 26 days, the worst on December 28, when there were 50 pending calls with no ambulances available, according to dispatch records obtained by the Express.
In an average month, the county's EMS system is at level zero for only 100 to 160 calls, or about 1 percent of total, according to county records. But this is only the most extreme measure of the problem. Even when the system is above "level zero" there are still delays.
But this frustrates local fire departments, who have to pick up the slack even when it's not at level zero. Dave Brannigan, deputy chief of the Berkeley Fire Department, described the county's current ambulance service as "very understaffed."
"They don't have enough units and are frequently calling us to cover in Oakland, which we do when we have the units," Brannigan told the Express.
Private ambulance contracts with counties include requirements for minimum response times, which align with varying levels of medical emergencies, from the lowest priority (Alpha), to something potentially fatal (Echo), which could be anything from heart attacks to gunshot wounds.
But critics ding ambulance companies for rating calls at a lower priority, meaning that ambulance drivers can take longer to get to a call without being at risk of violations or higher fines.
For instance, in February 2013, a call came in to the Alameda County dispatch system that a man in Castro Valley was "not feeling well." It was given the lowest priority available. But the man — who had undergone open-heart surgery and had half a lung removed less than a year prior — was actually experiencing a major heart attack.
Dispatchers initially sent a Paramedics Plus ambulance, but within a minute it was diverted to another call. The man's priority ranking was immediately upgraded, though, when paramedics with the fire department arrived on the scene, and he was transported to the hospital. He survived.
Paramedic Plus also often classifies shootings, stabbings, and other medical emergencies that should be Echo, or the highest priority, as a lesser urgency.
One incident involved a 5-year-old boy who was shot in Oakland's Fruitvale neighborhood, which was classified as a Bravo call, the second lowest priority, according to a 2013 investigation by NBC. The boy died in his father's arms.
Travis Kusman, Alameda County's EMS director, defended Paramedics Plus' performance. He wrote in an email to the Express that the company's response to emergencies is improving, thanks to the county's dispatch system. He said the fines levied against Paramedics Plus were for individual calls that fell outside stipulated response-time requirements.
Kusman used to work for Paramedics Plus, but he doesn't mention that on his LinkedIn profile.
"Paramedics Plus continues to meet or exceed contractually required response times system-wide and has done so since inception of service provision to the county in 2011," he wrote. "On average, year to date, Paramedics Plus ambulances arrive on scene in just over six minutes when true and obvious critical time-life situations exist."
That said, not making these calls has been costly for Paramedics Plus: Since 2011, the county has fined the company nearly $9 million for both failing to hit its response times and also not maintaining adequate patient records.
Finances are a critical issue for Alameda County's EMS operator. Even though it's a for-profit company, Texas-based Paramedics Plus hasn't been able to turn a buck here.
While the outfit's contracts in Indiana and Florida brought in a combined $2.5 million in profits in 2015 — as Paramedics Plus's president Ron Schwartz told the Alameda County's board of supervisors that year — the company has lost $48 million here.
The company attributes this to having to pay for paramedics on local first-responder fire trucks, the previously mentioned fines, and low reimbursement rates (for instance, Medi-Cal repays less than $117 for expensive ambulance rides, and two-thirds of county residents receive government health insurance).
This, in part, prompted Schwartz to ask the county for a $5 million bailout in 2015. The board narrowly rejected his request. But weeks later, the supervisors approved a $4 million deal.
"We pay the county over $7 million a year," Dale Feldhauser, head of Paramedics Plus in Alameda County, told the Express. "We were asking to not pay the county this one time" he said of the 2015 vote.
"On average, year to date, Paramedics Plus ambulances arrive on scene in just over six minutes when true and obvious critical time-life situations exist."click to tweet
EMS systems are finding out there's less money available every year, as funding sources are fickle under market trends and other factors. Still, while relatively young, ambulance services in the United States are now a $14 billion industry, and one only expected to grow as the population ages and people live longer with more chronic conditions, according to a report by financial-research firm Dun & Bradstreet.
Looking to save money and increase profits, EMS providers are exploring everything from hiring less-trained (read: cheaper) labor for calls with lower medical necessity to relying more on volunteer "community paramedics," like the People's Community Paramedics in Oakland.
Some are even partnering with Lyft and Uber to help handle non-emergency calls.
But across California, the private ambulance lobby also is looking to cut costs by targeting worker's rights.
On the Backs of Medics
Prior to 2010, American Medical Response — one of the largest ambulance providers in the United States — ran Alameda County's ambulance services for nearly two decades. But then it was outbid by Paramedics Plus. More on that — including the lawsuit against Paramedics Plus and the county — in a bit.
Mike Taigman, one of the founders of Paramedics Plus who later headed AMR's Alameda County shop, left with AMR when it parted ways with Alameda County. But he actually warned county officials that the switch to Paramedics Plus' system would fail, and that it would be costly to fix, all the while jeopardizing the health and safety of East Bay residents.
"[Paramedics Plus] signed up to a pretty difficult contract," Taigman told the Express.
Taigman also added that "Alameda County paramedics are loyal to people in the county, regardless of who the contract is with. It's a part of the DNA that you won't find in other counties in the country."
As part of its contract, Paramedics Plus was required to on-board a large number of paramedics and EMTs working in the county. Large swaths of its management, however, were brought in from other areas.
It wasn't a smooth transition.
"The fact that EMS workers make less than fast-food workers was surprising."click to tweet
The majority of the nearly 250 Paramedics Plus employees surveyed by the county EMS a year into the contract felt they didn't get the proper training or equipment needed to do their jobs. They described the leadership at Paramedics Plus as a top-down, unapproachable management team that failed to provide critical information related to working in ambulatory care in Alameda County.
Nearly 90 percent of the survey respondents felt Paramedics Plus also caused unreasonable stress in their lives, and its leadership wasn't held accountable for problems. A statement on the county's EMS website said improvements would be made, but no follow-up survey has been posted since 2012.
But, according to state records and interviews with employees who did not want to be named, working for Paramedics Plus remains frustrating and "less than ideal."
Besides being emotionally, mentally, and physically exhausting work, employees of private ambulance companies are often paid below the federal poverty line. This is industry-wide in California, as 80 percent of the state's EMTs and paramedics work for private ambulance companies.
A study by the UC Berkeley and UCLA labor centers released in February found that EMTs and paramedics working for a private EMS services in California earned an average of $16.59 an hour — a rate that continues to drop — while working in high-risk situations with low labor standards.
Those working in government-run EMS systems were paid nearly 40 percent more, and had better working conditions, the study found.
"It's marked by low-wages, a high-stress environment, and high turnover rates," explained Ken Jacobs, chairman of the UC Berkeley Labor Center and researcher.
"The fact that EMS workers make less than fast-food workers was surprising."
One common practice with private companies is "posting," or requiring ambulance workers to sit in their vehicles in between calls. This, researchers say, "places significant hardships on EMTs and paramedics" by increasing the chances of back pain, and decreasing the likelihood of a break during shifts that often last twelve hours or more.
All of this is why Freddie Rodriguez, an EMT for more than 30 years and now a state Assembly member from Southern California, introduced what's being called the EMS Workers' Bill of Rights. This proposed law would mandate meal-breaks for emergency workers (barring major emergencies, of course), increase access to mental-health resources, and track violence against workers.
"These first responders are there to take care of us, but really who's there to take care of them?" Rodriguez told the Express.
He still picks up a shift on occasion — but his employer, AMR, is against the bill.
Even more, the California Ambulance Association — the state's private ambulance company lobby — wrote its own bill, which included provisions to exempt the EMS industry from mandatory break periods, and to relieve employers from compensating employees for denying them no-contact breaks. The bill has been stuck in committee since April.
In the ambulance industry magazine Siren, CAA executive director Ross Elliott referred to the UC study as "fake news" and "propaganda" that exaggerated problems in the private ambulance industry. He argued that statewide policy — Rodriguez's bill — shouldn't be passed based on its findings.
Elliott also played the public-safety card: "If such a rule is applied to the ambulance industry, it potentially puts communities at risk."
'The Hits Just Keep on Coming!'
In May, hours before Alameda County's board of supervisors would approve a new Paramedics Plus contract, Dr. Karl Sporer spoke at an industry conference. With decades of experience in emergency medicine, his words were fast and concise, peppering inside jokes with industry jargon — ALS, 4D4A — and statistical analysis.
Sporer, the medical director for Alameda County EMS, was a featured presenter at the annual Emergency Medical Services Administrators' Association of California conference in San Diego. Also known as EMSAAC, its primary sponsors are ambulance companies and groups such as AMR and the CAA.
The gathering included people wearing many hats in the field. Some start as employees of ambulance companies and end up as representatives of the regional authority overseeing those contracts. Featured speakers pinpointed several areas that were hurting EMS systems across the state, from public insurance reimbursements to Millennials. Common themes included convincing politicians, the public, and the press that response times are not the most important barometer of success (although they're the first thing mentioned when evaluating an EMS system's effectiveness); and limiting the presence of fire departments in the EMS system.
This year's state EMS conference was baseball-themed, with the title "The Hits Just Keep on Coming!" Whether those hits are positive or negative depends on your vantage point.
Sporer told attendees about Alameda County's medical-priority dispatch system, which routes 911 calls by severity, allowing less important ones to be bumped for more serious emergencies. He explained how using this tiered-response system can help EMS systems save money.
"We tried to put this kind of optimization into our last RFP, but it's been put on ice for the last six months," Sporer said, garnering chuckles from the audience.
Brian Krans
Dr. Karl Sporer, the county's EMS medical director, at an industry conference this past May, the same day the county board approved a new Paramedics Plus contract.
Not everyone was in on Sporer's joke, but here's what happened: Last year, Alameda County submitted for state approval two plans to contract with the county, otherwise known as a request for proposal, or RFP. This was a highly unusual move; normally, there's just one.
The first RFP aimed to continue the private-ambulance-provider model that the county has used for nearly half a century. The other was an "alliance model," a contentious plan where the fire department — not the county's EMS board — contracts with a private company.
Contra Costa County began using this alliance/fire department model in 2016. Since, the Alameda County Fire Department has been talking with the county board about potentially adopting a similar approach.
But private industry views the fire department as a threat. And, in June of last year, its lobbying arm, the CAA, sent a letter to county and state officials calling its bidding process "seriously flawed and unfair."
Elliott, the CAA's head, even alleged in this letter that the "unorthodox" RFP process violated anti-trust laws — i.e., it was the county choosing itself as the provider, since the board of supervisors is also the fire department's board of directors.
But Adam Willoughby, spokesman with the Emergency Management Service Area, which oversees EMS contracts, told the Express in an email that his agency never received any official complaints about the county's alliance-model.
He also added that currently "there are no specific types of ambulance model RFPs that are banned in California, nor are any preferred by EMSA."
Still, Alameda County's most recent bidding process ended up excluding the alliance/fire department model.
According to public records obtained by the Express, Sporer emailed state officials — including to EMSA director Howard Backer, who lives in Alameda County — on June 12, 2016, and requested that they write formal letters asking for more time to study the alliance RFP.
"I am interested in this letter stating overtly that this review will take 6-12 months or more than 6 months or something similar," Sporer wrote to Backer (he sent this via his email account with UC San Francisco, where he is also a professor). "This will alleviate any pressure to just wait out a suspected 4 or 5 week turn around for the other RFP." He also sent another email on August 1.
A spokesperson for EMSA told the Express that Sporer's emails shouldn't be interpreted as pressuring a state agency for specific action, but instead as an attempt to clarify timelines.
Backer eventually wrote a letter that stated that the alliance model couldn't be approved while anti-trust and other legal issues were researched. "EMSA does not know how long this research might take, given the complexities of the RFP," the August 12 letter stated.
Soon after Backer's letter, the county released a lone RFP, which specifically stated that the alliance model wasn't being considered.
Fire officials say they were alarmed by language in the RFP, however, including statements that there was "little data regarding the effectiveness or ineffectiveness" of the alliance model, and that letting the fire department run EMS was "potentially violating anti-trust and other laws."
"Alameda County is a large urban jurisdiction and without a tested and proven 'alliance' model, given our County's complexity, the EMS Agency feels that it is not prudent to experiment at this time," the county's RFP stated.
This irked fire chiefs, who thought they were going to be able to put in a bid.
Alameda County Fire Chief David Rocha says it was interesting that not only did the RFP ban the alliance model, it also went so far as to critique it in a public bidding document. "I could not answer the question as to who put it in there, but it was something that was very noticeable to us, at least to me," Rocha told the Express.
Officials with the state EMSA also noticed the criticism.
"My phone is on fire over the Alameda RFP," wrote Tom McGinnis, EMSA's systems division chief, in an October 3 email to co-workers and obtained by the Express. "For Alameda to directly call out alliance models and say they can't bid is going to be a VERY hard thing for us given we have said any qualified entity should be allowed to bid."
His boss, Backer, responded the next day and stated Sporer never mentioned the county including any clause prohibiting fire departments from the bidding on the county's contract. "I suggest we discuss this in person rather than email," Backer wrote.
The firefighters' unions and fire chiefs demanded that the RFP be immediately canceled. Burrows, president of the Alameda County union, claimed the bidding process was intentionally manipulated to exclude the fire department.
"They chose to do that because of the fear of the fire department," he said. "We just want an opportunity to compete in the process."
Sam Zide
Sean Burrows, president of the Alameda County Firefighters union, wants a chance to bid on emergency-medical services contracts.
Sporer, contacted in-person at the EMSAAC conference and via email, declined to discuss this and other issues for this story.
But Rebecca Gebhart, head of the Alameda County Health Care Services Agency, said the email exchange with state officials is part of a larger conversation, both written and oral, about concerns with the alliance model, including dialogue with the California Attorney General and the Fair Political Practices Commission. She said Sporer's emails were "not an attempt to influence or suggest what the timeline should be."
Gebhart eventually pulled the non-alliance RFP in October, before anyone could bid, leaving Alameda County with less than a year before its contract with Paramedics Plus expired November 1.
But then, the county signed another contract with Paramedics Plus — this one much more in their favor.
'Kickback Schemes'
The friction between private ambulance industry and fire departments is nothing new. During the late Nineties, the EMS authority overseeing Tulsa and Oklahoma City was struggling financially through its private ambulance contract and faced competition from fire departments, which wanted the authority to handle ambulance services on their own.
If that happened, "EMSA would have no reason to exist, and, presumably, EMSA employees would lose their jobs," according to a federal whistleblower lawsuit unsealed earlier this year.
So, the head of that EMSA met an executive of a nonprofit health-care system in Texas at an EMS conference in Florida. Federal authorities allege the following scenario went down: The nonprofit started an ambulance company that "would funnel portions of its proceeds" back to the government board overseeing it.
Soon, Paramedics Plus was formed. And the company was awarded a more than $100 million contract for Tulsa and Oklahoma City, despite having never provided ambulance services before.
Federal prosecutors say this constituted a pay-for-play scheme that defrauded taxpayers and helped Paramedics Plus skew the bidding process for multimillion dollar contracts in its favor.
A similar "profit cap" scheme was written into Alameda County's original contract, but it ultimately backfired. The 51-word provision cost the county $71,400 as part of a settlement with federal authorities this April.
"Kickback schemes are anti-competitive, undermine the integrity of our nation's health care programs, and wrongly prioritize profits over patient care," Brit Featherstom, acting U.S. Attorney for the Eastern District of Texas, said in a press release.
Alameda County board counsel Donna Ziegler told the Express that, because the contract never returned a profit, the kickbacks were useless. "The county did not receive one penny," she said.
The new version of the contract with Paramedics Plus had that language taken out.
"No one really knows what they're doing. EMS is like a baby running around pissing itself."click to tweet
The company's new contract with the county, which it approved in May, also removed a requirement that it pay nearly $5.5 million to support the county's voter-mandated first-responder fees, which covers the cost of fire-department paramedics. Paramedics Plus had paid more than $27 million in those fees since 2011, according to county health department records.
It also will be paying far less — to the tune of $3.5 million — for not meeting call time responses, which have been significantly relaxed since its first contract. And now it can delay buying new ambulances, for up to 350,000 miles.
Besides response time call violations, fines and settlements for fraudulent billing practices remain an issue for the for-profit ambulance agency. The lawsuit against Paramedics Plus also alleges they defrauded Medicare. But it's not alone.
Other ambulance companies have been charged with submitting false claims, while some individuals are serving jail time for that fraud.
In 2015, the Office of the Inspector General conducted an investigation into the nation's ambulance industry, as it is a common source of Medicare fraud. It found that one in five ambulance providers had questionable billing practices, namely in metropolitan areas. "Investigators have uncovered a variety of fraud schemes involving ambulance suppliers," the report stated.
Besides advocating for closer scrutiny of ambulance billing practices, the report found about twenty areas of the country that had especially high rates of questionable bills.
Mercifully, none were in the Bay Area.
'Power and Control'
In January 2016, the Contra Costa County Fire Department began using its "alliance" model. In it, the fire department is the ambulance provider, which then contracts through a private ambulance company, AMR. The two have a shared dispatch through a regional communication center.
Terence Carey — who worked for the Alameda County fire department until he retired last July — is now the assistant chief of the Contra Costa County Fire Department. He said the new system consolidated many processes, including on-scene communication that better prepares responding ambulances. "Whatever unit gets on scene first collects the information, hits a button, and sends it to the ambulance," Carey told the Express.
According to department numbers, relevant response times the first year of the alliance model were reduced by more than half. And during its first year, the alliance model netted Contra Costa County more than $6.7 million, according to a report released in May.
With these numbers, Carey says the new fire department-led public-private alliance model is working. "We're doing this and we're truly cutting-edge," he said. "I think a lot of people are really interested in it."
Not everyone.
The CAA's Elliott said in a letter dated April 4, 2016, that Contra Costa's bidding process didn't allow for fair competition, but did grant the county fire department the authority to "completely control and dominate the EMS system in Contra Costa County."
"Although county administrators may be motivated by significant additional revenue to create the alliance, [Fire] District personnel may be motivated by power and control," the letter stated.
Carey is aware of resistance to the alliance model from private ambulance providers. "I don't fault anyone in this conversation so long as they're not twisting the facts," he said.
Back in Alameda County, Rocha says because fire units are already showing up first — as about 70 percent of all calls they handle are medical emergencies — it makes sense to allow fire departments to enter the bidding process.
"I've got a pretty good understanding of the actual system, and there are things in the system that are problematic," he said. "They need to be fixed."
But whether the county fire department will be invited to the bidding table this time around remains to be seen, even if done in a public and transparent way. After the board of supervisors approved the latest Paramedics Plus contract in a 3-1 vote, Gebhart said the RFP bidding process could be open by the end of May. But it's now July, and it's still not open. Taxpayers continue to pay millions to help subsidize Paramedics Plus.
"I will reserve my comments until I see another RFP," Rocha said of the situation and laughed. "I would have not believed on this last RFP that that would have happened. It really surprised me that we were not able to participate."
Back at the state EMS conference in San Diego, Bryan Bledsoe, a former EMS director in Texas, was the closing speaker. He said no one gets rich running ambulances in the United States unless they're committing fraud. "But they get caught," he added, with a chuckle.
Paramedics Plus was not a sponsor of the conference.
At the end of the first day, at the hotel bar, a representative from a Texas company that makes an EMS app, said conferences like these are all the same, as people transfer from private companies to EMS agencies meant to regulate them.
"No one really knows what they're doing," he said. "EMS is like a baby running around pissing itself."
Brian Krans is the Investigative Reporting Program student merit fellow at the UC Berkeley Graduate School of Journalism.