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Mayor's Board Room
Wednesday, July 27, 2011, 10:00 AM
Book: 65, Page: 1

Special Meeting

Called To Order The meeting was called to order by Whatcom County Council Chairperson Sam Crawford

Roll Call
    Barry Buchanan, Council Member, Third Ward
    Stan Snapp, Council Member, Fourth Ward
    Michael Lilliquist, Council Member, Sixth Ward



Meeting of the Medic One Policy Group
Garden Room, Whatcom County Civic Center Building


Bellingham City Council (EMS Committee): Barry Buchanan, Stan Snapp, Michael Lilliquist
Whatcom County Council: Sam Crawford, Barbara Brenner, Kathy Kershner

Other participants: Al Saab, Dave Ralston, Tom Fields, Gary Russell, Dewey Desler, David Webster.

Sam Crawford reviewed the status of the planning process and the purpose of the meeting. Subcommittees of the planning group have been meeting. This July meeting is to take stock on whether the process is on track to create a new unified system. In September a new draft interlocal will be developed. Politicians need to stay out of the planning process. Today we will get reports back from the finance, business model, and training subcommittees.

Dave Ralston. Bill Boyd and myself are co-chairs for the EMS planning group. The group is meeting every other week. There are business model, finance, and training subcommittees. Medical control and Quality Assurance, and billing and recordkeeping are also part of the discussion, although this is part of the business model subcommittee. The business model is a key component. Today we will provide updates but do not have any recommendations. We don’t have consensus but the process is still moving forward. Creating a draft for the Policy Committee in September is the goal. There are some decisions and tough choices to be made. On finance, less work is completed. Some additional dollars may be needed but these may be balanced by other efficiencies.

Tom Fields. Developing a new business model is complicated. We looked at the County resolution, and took input from the city. Transparency is the goal. There are City-County political issues. A governing board would be three members of each Council. They would hire an administrator to run the system. We would look for efficiencies, such as centralized billing and data collection. A permanent planning group, which would be advisory and include other stakeholders, would meet with and advise the administration. We are working through the issues of all of this.

Al Saab. We sat down with the finance subcommittee and they gave us some recommendations too. David Webster made up the matrix and we are examining how each activity will work. We will want to attach dollars and cents to the activities.

Barbara Brenner. So this is the model everybody’s working off of?

Al Saab. This is what we’ve come to a general consensus on, with a few exceptions, especially that it does not incur large additional costs.

Bill Boyd. I’m on the finance subcommittee and we’ve been looking for some direction from the business model committee so we can begin costing things out. When it comes down to dollars and cents we need to see if this is realistic from a financial standpoint. This is a complicated model, what it comes down to is if it is financially feasible. A lot of this will be cost-shifting. In some cases costs will be borne by Medic One and other cases the fire districts.

Stan Snapp. Shouldn’t dispatch be under an administrator instead of off to the side?

Tom Fields. Dispatch would need a liaison to the administrator. They advise but do not report to the administrator. There is not direct control of dispatch administrative costs, they are a totally different management group. Dispatch reports to other groups. They do have input into the annual budgeting process.

Stan Snapp. I would think that dispatch would need to be answerable to the administrator in terms of procedures and protocols. If an incident starts sour it stays sour, if it starts good it stays good. It is such a big part of the operation.

Tom Fields. This dispatch is a whole different process. Dispatch responds to the 911 administrative board. That’s the system of control.

Barry Buchanan. What is the charge of the new planning group? Would it meet with the administrator in an annual program or budget review?

Tom Fields. Its role would be program review.

David Webster. It would create a strategic plan for the system and monitor implementation.

Kathy Kershner. Is training part of this?

Tom Fields. You will hear more in a moment. Training could be under the administrator, or separate. It is not yet decided.

Dave Ralston. The Councils as a whole would still approve the budgets. The governing board would go back to their respective bodies for approval.

Tom Fields. The governing board is a consensus group. If consensus cannot be met, then they go back to the administrator and then bring it back to the Councils.

Dave Ralston. We are doing parallel planning. If the system cannot remain unified then we can take these components and create a separate system.

Al Saab. Fire District #7 already has an organization and adding another medic unit there would be the most logical.

Dave Ralston. The finance group will move to cost analysis next. The next item we will discuss is finance.

Bill Boyd. We have identified and validated revenue streams. These include the general fund, fire agency revenues, etc. Total revenues are greater than projected in the 2005 plan. We will look at a 2% sales tax revenue increase factor through 2014, and then 3% through 2017 as a planning assumption. Billing is $200,000 below budget this year. We assumed District 7 would siphon off some of that revenue and result in $240,000 shifting to District 7. Current revenues are actually trending $200,000 below that. There are more Medicare calls, and private insurers are cutting rates to Medicare levels. We are reviewing budgets and will look at all major cost centers. Personnel is the highest followed by dispatch. It is not clear everyone used the same assumptions. Next we will evaluate cost changes resulting from organizational changes. Some functions could go to a not-for-profit. We will look at it line-item by line-item. If contracted out, what would the cost components be? Some costs would need to remain within the contracting agencies. Some costs would remain in-house such as data management, administrative support, billing, HIPAA compliance, public disclosure, etc. We will build an expenditure forecast.

Kathy Kershner. What are the obstacles to centralized billing?

Bill Boyd. Centralized billing is on the table. Each fire district has its own contract for BLS billing except District 14. There is no centralized data collection for long-term planning, quality assurance, etc. We need to move in that direction. Some chiefs will not want to lose revenue. We need to support data collection for long-term planning and quality control. Centralized billing is a no-brainer. Medicare billing is becoming more complicated. With contracting out you lose control and you still need to have in-house support for billing.

Dave Ralston. Each agency will still bill Medicare for BLS. Before, Medic One did it all. Each agency doing a transport will bill Medicare.

Sam Crawford. Is that a new Medicare rule? (Group replied yes).

Michael Lilliquist. It seems that a centralized ALS system is good. We may need to do decentralized billing for BLS.

Gary Russell. Centralized billing can be done but for BLS and ALS it has to be pass-through. Under Medicare it goes to each entity. Local costs are still incurred.

Tom Fields. Data collection is weak and inconsistent. We can’t get an overall picture. Centralized billing will help with that.

Bill Boyd. Medicare billing is getting worse. The transporter is liable for fraud. Multimillion dollar fines are being levied. If there is a case of fraud all Medicare reimbursements are suspended. 50% of reimbursement is from Medicare.

Barbara Brenner. There are lots of ways to bill. How difficult is it for everyone to adopt the same system? We can still send the checks as a pass-through.

Bill Boyd. Up until 2005 we had one entity doing all EMS transports. Now 11-12 entities are doing transport. It is hard to get everyone to change. If a district is getting something I think we can get there. BLS is creeping into the discussion.

Tom Fields. Data collection can augment billing. We can assume there will be the same billing protocols. The problem is in planning. There is no standardization. We need a cleaner system.

Gary Russell. Everyone uses the same procedures for billing. For us it was not cost-effective to contract billing out. It is also more expensive to go through Medic One.

Sam Crawford. Medic One charges $30 for billing and your system is in the $20 range?

Gary Russell. We charge $20.00 per pick-up. We are moving to e-billing instead of paper.

Sam Crawford. $20 does not cover other costs.

Bill Boyd. There is an economy of scale there. Administrative support needs means that in-house is the best choice. There are Medicare data submission requirements as well as audits. In 2014 Medicare will require credentialing of all employees, including background checks and fingerprinting. We’ll also have to sign separate contracts with all transportation providers to get reimbursements.

Dewey Desler. There is administrative capacity of $1.9 million. $900,000 of that was dispatch fees. You need to identify the roles and authority of each entity before it can be costed out.

Bill Boyd. That number is out there. This includes paramedic training, billing, quality assurance, etc. We assume cost-shifting. For example some of the costs borne by Medic One will transfer to this agency. The remainder is the issue now.

Dewey Desler. You need to compare new v. old authorities and responsibilities to define differences and attach costs.

Tom Fields. The governance board will oversee the administration. It will set overall policy and minimum service levels. We have developed a list of the roles of the administrative authority.

Dewey Desler. It is still a work in progress. The organizational chart does not identify who is going to do what. The dollars follow the architecture.

Al Saab. We are still reviewing activities to see who is responsible for dollars and cents. Then we can build a budget.

Dave Ralston. Regarding training, we looked at current programs. One is a certificate program and the other is converting to a degree program. We also discussed whether we want to participate in training. We could just hire certified paramedics. What is the definition of paramedic training? The hospital group wants people who are going to serve in Whatcom County if they are going to get skills at the hospital.

Gary Russell. We have identified current training programs and reviewed course requirements. Right now there is only one training program, at WWU. We just finished two classes. In 2014/15 we may need another session. Western is a certificate program and BTC was a certificate program but is in the process of converting to a degree program. There are no other programs in the area. Open training is in the context of available training. Agencies would sponsor, including the ambulance ride time to the hospital. Training needs to be accredited and certified, to accept people regardless of employment and union affiliation, and have a Whatcom County focus. St. Joseph’s has no interest in training responders who will work outside the county or regional system.

Sam Crawford. Does St. Joes include Skagit and San Juan?

Gary Russell. The service area is Whatcom, Island, Skagit, and San Juan. It may not be cost-effective just to train three people. If a program included other participants perhaps they could contract with other hospitals to train the non-Whatcom group. We want a certificate program not a degreed program. Some programs may be moving to a four year program.

Sam Crawford. BTC is not interested in doing that?

Gary Russell. They are interested in moving toward a degree program.

Barbara Brenner. Can you explain the difference between accredited and degreed?

Gary Russell. They all have to be accredited by the national agency. Certificate means you get a certificate and degreed means a two year AA degree. There are three classes -- mathematics , language and psychology. We could reimburse for prerequisites but not pay for time in school. The City of Bellingham has not wanted to go to a degree program, there is a cost involved with their labor group. Everybody keeps raising the bar but no one talks about what things cost, they are even talking about a 4 year degree.

Bill Boyd. They want something continuous and sustainable. We can’t assemble yearly classes. It does not make financial sense.

Michael Lilliquist. Could you repeat the definition of open enrollment?

Gary Russell. That means allowing enrollment in an accredited certified program with people selected without regard to agency or union status. All agencies screen who can go into a program. We have a probationary period and requirements for patient contacts. There would be a pre-test and not all would pass.

Michael Lilliquist. Preference is given to individuals who have a sponsoring agency. In the future, who can be a sponsoring agency?

Gary Russell. The providers are sponsoring agencies. If an organization is losing two people they could sponsor two trainees. Or we could hire laterally but require people to qualify locally. We don’t know if people would succeed. Our protocols allow a lot of latitude in the field.

Michael Lilliquist. The administrator could set level of service. Each contracting agency would decide how to assemble its crew. If an agency wants to train extra employees who pays for that?

Al Saab. An issue came up, why should we pay for training. Maybe the providing agency would absorb the costs.

Michael Lilliquist. Perhaps an agency would be accountable for the cost.

Al Saab. If they want ten extra paramedics then they pay for that.

Gary Russell. Bellingham has more paramedics than they need. If they are not working as paramedics they are not paid for that. Training costs are borne by the system. This could be a separate budget item reimbursed by each agency.

Bill Boyd. We have not drilled down to that level of detail. We haven’t discussed whether we will allow the administrator to decide who gets trained. We’ve defined open training and the biggest issue has been certificate v. degreed program.

Michael Lilliquist. We could set LOS and let contractors decide.

Al Saab. Thurston has a property tax levy to pay for this.

Kathy Kershner. We should consider not paying for training. It is a lucrative career.

Barry Buchanan. Is there discussion of standardization of pre-requisites for the various agencies?

Bill Boyd. There is no coordination on how students are accepted. A new system should have standards. It would be good to have a level playing field, for example how many patients someone has worked with.

Tom Fields. This ties directly to the business model. If we need a new medic unit that training takes priority, taking precedence over just adding to numbers of EMT’s. The administration can facilitate but shouldn’t have to pay for training.

Sam Crawford. If we take trained fire personnel they are highly skilled and there is a benefit to cross-training. I have a concern if we have our fire personnel and we just go hire paramedics.

Tom Fields. If someone wants 12 new people, the job description would be both firefighter and paramedic. A question is whether we should bear all the cost of overtime and other costs.

Sam Crawford. How does that work. There will be openings in 2014. If someone is a full time firefighter how would he get training?

Barbara Brenner. It could be a combination.

Michael Lilliquist. Would people take on the risk to pay for training? We could have a contract, if you get the training you will be considered, you will get reduced hours and time off but will pay your own tuition.

Audience member. If hiring was just lateral that would be a discrimination against our current employees.

Audience member (2). It is about self-initiative. The average firefighter makes between $70,000 and $90,000 and people work 8 days a month on average and there is time to get training.

Bill Boyd. Federal labor law must be dealt with. Much of training is productive work and is done alongside paid staff. Sustaining training is difficult and complex.
Sam Crawford. Let’s recap. We are moving forward to a unified system. We will get a draft of the interlocal. We need a time frame to establish a new system. Where are we at?

Barbara Brenner. It sounds like progress is being made.

Sam Crawford. We need feedback – are we on track?

Dave Ralston. There are no red flags to moving forward. If in September there are too many outstanding issues that is not good.

Bill Boyd. It takes three months to get guiding principles. An interlocal won’t happen by September, it is too time-consuming.

Sam Crawford. What are the right expectations for September? Is it too soon for an interlocal? What about by September 30?

Bill Boyd. We can identify guiding principles and overarching conceptual agreements.

Tom Fields. Is the business model fitting with your overall direction?

Sam Crawford. It is also a question of money. Can we afford a new system?

Michael Lilliquist. The model looks good. It sounds like a reasonable system.

Sam Crawford? Can we wait until October 31?

Dave Ralston. Perhaps we can still meet in September.

Sam Crawford. We can delay until October if there is not enough time.

Kathy Kershner and Barry Buchanan. I’d prefer a September check-in.

Dave Ralston. I’ll take it back to the planning committee and tell you if we are ready for September.

Sam Crawford. So we’re tentatively keeping September.

David Webster. We will work out the relative costs. We need to assume a transition to a new system. There may be parallel systems for awhile that would have to be paid for.

Sam Crawford. We have not identified a specific time. What about Wednesday 10:00 AM the last Wednesday of September?

There being no further business, the meeting adjourned at 11:30 AM.
Barry Buchanan, EMS Committee

ATTEST: Mark Gardner, Policy Analyst

This is a digital copy of an original document located at Bellingham's City Hall. The City of Bellingham specifically disclaims any responsibility or liability for the contents of this document. The City of Bellingham does not verify the correctness, accuracy, or validity of the information appearing in this document.