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HomeMy WebLinkAbout2005 04-19 Pre Meridian Citv Pre-Council Meetina April 19.2005 The Meridian City Pre-Council meeting was called to order at 6:00 P.M. on Tuesday, April 19, 2005 by Mayor Tammy de Weerd. Members Present: Mayor Tammy de Weerd, Keith Bird, Shaun Wardle and Christine Donnell. Members Absent: Charlie Rountree. Staff Present: Ron Anderson, Kenny Bowers, Joe Silva, Ted Baird and Will Berg. Item 1. Roll-call Attendance: Roll call. ~ Shaun Wardle ~ Charlie Rountree ---X-Christine Donnell ~Keith Bird ~ Mayor Tammy de Weerd Item 2. Adoption of the Agenda: Bird: Mr. President. Wardle: Mr. Bird. Bird: I move we adopt the agenda as published. Donnell: Second. Wardle: It's been moved and seconded to adopt the agenda. All in favor? ALL AYES. MOTION CARRIED. Item 3. Ada County EMS Presentation for Proposed Bond Levy: Wardle: I am going to begin with this just real briefly on some background on our meeting this evening. As many of you are aware, there is a proposed bond levy for the Ada County EMS. We as a city and elected officials wanted to get more information about this specific bond. We have asked Troy Hagen from the Paramedic EMS District to begin a presentation for us this evening. The goal of this evening is to get more information from the elected officials for our public service staff as well as our partners in the EMS and so with that Troy I am going to turn this over to you. Meridian City Pre-Council Meeting April 19.2005 Page 2 0121 Hagen: Council and Mayor thank you very much for giving me the opportunity to come and speak with you tonight. We will just jump right into the presentation. I think you will find it very informative and hopefully we will provide or answer a lot of your questions and we will have time at the end, I think, to get more questions as they come up. We will just get right into that. First of all a little bit of background on Ada County EMS. We were established in 1975. We just celebrated our 30th anniversary of providing coverage to Ada County and we are very proud and happy of that. The reason that we came to be in the first place is when the private providers that were doing it at the time went bankrupt. The county went into - evaluating the system at the present time with the task force, which I will get into - to figure out how is the best way to provide EMS to Ada County for the long term and the Ada County Commissioners created an ambulance tasking district back then in 1975 under 31-39-08, which is Idaho Code. So, just prior to that there was a task force that was made up primarily to medical community that met and they went in and they traveled up to Seattle and looked at many different systems that existed at the time, which there were not very many 30 years ago and said this is the best way to do it. Seattle has done a good job of setting it up and just kind of the father of modern day EMS is the Seattle based system and so we set up our system very similar and it was a tiered response, meaning that - what that means is that basic life support is they try to get there with the goal of four minutes followed by a smaller core competency of more advanced and more highly skilled paramedics, but follow that up with an eight minute response time standard where you can really optimize the care. So, very similar to if you go and you see a general practitioner, they may have to refer you to a specialist, well not everybody a specialist because the demand isn't necessarily there for that, but there is lots of demand for general practitioners. Kind of the same thing in the EMS. The EMT is a basic level of a way to start. They can do many of the different things and ten follow up with that higher up care. So, that is the system that we have worked today is a tiered response system. That comes to be very important as we continue on with discussions from here on and into the future about why we have a tiered response system. There are currently seven fire departments and 27 fire stations in Ada County that provide basic life support (inaudible) life support. Back at that time they said the fire department is the perfect choice to be able to provide that basic level of care. There are a lot more stations and there are a lot of them and it really fell in line with what their function of rule could be and so to us it was a natural fit into the task force. It was a natural fit to be able to equip them and train them and get them out to provide that basic level of response. There is currently just one EMS agency in Ada County that provides a paramedic level of transport service. So, we do all the 911 calls and provide all of the ambulances and we do that with 12 different stations located throughout the county. Those 12 stations, not to the surprise of many, eight of those are co- located with fire departments as we speak. That's including the Cities of Boise, Meridian, Eagle and Kuna, where we have joint stations. We have three cooperative agreements. Three of our stations are with the local hospitals including St. Alphonsus and St. Luke's downtown in St. Luke's Meridian and the Meridian City Pre-Council Meeting April 19,2005 Page 3 0121 district actually only owns one station and that is our main administrative and operations office, which is also a medic station that is there down from Glenwood, down by Hawk Stadium. So, that's the only one that the district actually owns. Just a little bit about the differences in care. I touched on this, but an EMT basic is what every firefighter and paramedic out there is trained at this basic level and that is patient assessment, they can put on oxygen delivery, bandaging, CPR and the use of the automated defibulator and that also becomes a critical element and as we look at why four minutes. Why do want them there in four minutes? It's really is that is the time that has been determined to get - that if somebody needs defibulation if their heart was to go into sudden cardiac arrest. So, that's the key factor for a four minute response time is if they don't get defibulated or shocked within four minutes their survive ability rate starts to go down. Then the EMT advanced, there are a few departments that have gone to the advanced route, where you get some advanced patient assessments, a more airway management and also had the ability to do IV's. Then the paramedic schedule - the advanced patient assessment, even more stuff - this is where you really start getting into cardiology, pharmacology, medication administration and really where it is a significant jump from one level to the next. This is typically from one to two years of education depending on the program that you have gone through. Last year we responded to 17,513 calls throughout the county and that call (inaudible) increases 67 percent annually. So, our system performance is really based on two different things. One is the response times that we have just talked about the four and eight-minute response times and it's based on clinical performance. A lot of times many systems will try to just say okay it's all response time, so we just need to get there and they put an ambulance or paramedic or even an EMT on every street corner and think that they are best serving the public that way and really the best thing that that does is drive up your cost. There has been no statistical data to support that - a flood of EMS providers is the best means of providing the service, it's just a matter of - there is a balance. You either have to have the - you need to get there quickly, but you also have to have enough skill and experience when you get there to be able to know what to do and to do it very well. So, there is a balancing act there. The tiered system in Ada County works with cooperation with local fire departments and the EMS agency and the hospitals and the system that we have been operating, it works very, very well. There is called a standard that is applied across the United States about cardiac arrest survivability. USA Today did a big article in 1993 in July where they took 50 cities and evaluated where they would be at using the standard. They took that exact same standard and applied it to Ada County and you can see where we were number two of second only to Seattle. So, I am very proud of that and that is really a joint cooperative effort between all of the fire departments and the paramedic department to be able to make something like that work. One can't do it without the other. It's very important. So the funding issue. Currently, or I should say historically we have been very reliant on user fees to help pay for our service. We have been at 30 percent tax base, 70 percent fee for service in our budget had been our makeup all the way up until 2002. So, really the majority of our funding came from that Meridian City Pre-Council Meeting April 19,2005 Page 4 0121 fee for service. We go out, we transport somebody or we evaluate somebody, they receive a bill for that service and we relied on those fees to keep our tax base very, very low. In fact, Ada County is one of the lowest in the state of Idaho for anyone's taxing districts. There is only one that is lower than ours and that is Blain County and ifs by a few tenths of thousandths of a point below us, but they also have much higher values than we do. That's what our current rate is at .0001227, which means that on a $100,000 of taxable value you pay EMS $12.27 per year. De Weerd: Mr. Chairman. Wardle: Madame Mayor. De Weerd: I am sorry, Troy when you talked about dissolving the district to the four and the recommendations from the Blue Ribbon task force, I believe, was 2 - 4, was that what it was? Hagen: 2 - 5 was the recommendation from the chair. De Weent What is the difference between - what is the monetary difference between what you were getting and what you would have gotten? Hagen: The monetary difference currently at that $12.27 thère, we generate $2.8 million dollars in tax revenue. If it would have went all the way to four - De Weerd: Okay, but what would it have been if you would have changed it to the Blue Ribbon task force recommendation? Hagen: To the .025? It would have been double that. So, roughly $4.6 million, or actually $5.6 million. De Weerd: So that difference was - I am not doing the math on that. What is the math on that? Donnell: 5.6. Hagen: It would be basically double of what we currently have because that's at $12.27 they are suggesting 2 - 5, so basically double that amount. So, that would have generated an additional $5.6 million per year. Wardle: Just to interrupt for just a moment I would like to welcome Councilman Rountree to the meeting. Rountree: Well, thank you Mr. President. Wardle: Please continue. Meridian City Pre-Council Meeting April 19, 2005 Page 5 0121 Hagen: If it would have gone to the maximum and really the maximum was there. The Commission never - you know they never made a decision amongst the three of them about what they would have set that levy at if they would have redistrict. They were still trying to get some from fiscal year 04 data in and so forth so they never voted on it to say yes, we are definitely going to go to .04 or anything like that - I think the reason for that slide is that we are at about one third of what the state maximum is and that had worked well for us for all these years up until the Medicare issue came to be. So, you can see just how far down below we were and how reliant we were on those fee for services. So, in 2002 the Medicare rule change hit and what that did was that prohibited us from balance billing the patient and just a few examples here, we now lose and this is a top ambulance bill that if we go out there and we do about every procedure that you do on somebody like a cardiac arrest, where you are doing a lot of different activities is about $1,200. Out of that $1,200 Medicare will pay about $370 and so we can lose up to $830. On average we are losing about $600 a call. So, that is pretty significant and we will get a little bit more detail there, but really what it does is - what the rule did is that it says okay it may cost you $800 to run your call, that's what you are billing out, but we are only going to give you $370. Prior to the rule change we were able to go and bill secondary insurances and we were able to then go to the patient and recoup the entire cost. With the rule change it says, no you have $370 or you have $270 and it just depends on what level that you are at, but that's it. Now you can go after the patient for a small portion of a co-pay, which on average is anywhere from $50 - $70, but the rest of it you have to write off. That's really where we ran into the significant funding deficit that we are talking about. Because 33 percent of our bill (inaudible) will transports our Medicare patients. So, there is - you know that's a substantial hit on an of our calls. Bird: Mr. President. Wardle: Mr. Bird. Bird: Can I butt in so I don't forget what I was going to ask? Troy, we are going based on heart attack calls, I take it. Out of that 17,500 calls, what percent of them are cardiac arrest calls because I know quite a few of them are accident calls, stuff like that so when you say you lose $600 on a cardiac arrest call, what about the other calls that aren't cardiac arrest? Hagen: The cardiac arrest calls are more of the $830 range. On average on all of our calls that we bill for is $600 per call and there is about - out of the 17,500 calls, about 12,500 of them are billable. Bird: Are they cardiac? Hagen: Every type of call. Meridian City Pre-Council Meeting April 19. 2005 Page 6 of 21 Bird: Thank you, Troy. Hagen: So, that reduction in our revenue is also in a time of rapidly increasing health care costs, as all of we are sure are well aware is that EMS is a health care agency and the cost of our medical supplies go up just as rapidly as they do in the hospital or anywhere else. Certainly we have our increase in demand - 6 percent a year is a pretty significant increase and certainly the depressed economy hasn't helped at all, either which has increased the bankruptcies, medical bankruptcies and stuff where we end losing more money because people can't pay their ambulance bills. So, here is the financial impact that we have had since 2002. Now the 2002 number, the rule went into effect on April 1 st. So it was halfway through our fiscal year. So, there is not a full value amount that can be realized in the first year. So, this is under six months of that. We lost $1.2 million in 2002 and you can see in '03 is $1.9; last year and these are actual numbers $2,048,000 that were strictly Medicare write-offs that we had to do. There was no way to collect on that dollar, which we could have previously collected prior to 2002. We are projecting for '06 and '07 to be $2.3 and $2.4 based simply on the growth that we have had. So, our total revenue loss from 2002 to 2005 is $7.4 million is what we have seen so far. Over the course of the next two years in 2006 and 2007, we expect that it be an additional $4.8 million. Just in a graphical format, pretty much the exact thing they just said. So, the issues that hinder our growth are certainly the recent cuts in Medicare. Medicaid quickly followed. They followed the same rule, which took up another three to four percent of our calls, about 3 percent, I think is what our transport rates are, which is a state supported federal program, so now it went from our 33 percent up to 36 to 38 percent of these patients and all federal health insurance companies follow the same rule. So, all the military and any postal service, any type of insurance that is federal insurance, they have to live under the same rules. The ambulance task and district base is limited by the 3 percent budget cap. which I am sure you are all very familiar of that 3 percent plus growth factor, so even if we wanted to increase our levy rate from beyond the $12.27, it's not going to -we can't get there with the 3 percent cap. So, our levy is pretty much stuck right in there fluctuating by a few tens of thousands of a percentage each year. Our EMS fees are already high. We did not want our fees to be a hindrance to somebody calling 911, so that is certainly a last resort to increase our fees any more, which would also just increase bankruptcies and people not paying their bills. So, it really wasn't a good option, certainly aren't going to make up over $2 million a year by an increase in user fees. So, what has been done? Prior to this in 1999, we raised our fees significantly. We knew this was coming, we just didn't know what the true impact was going to be. This is part of the balanced budget after 1997, the Medicare rule change and it wasn't implemented until 2002, so in 1999 we said okay the rules are going to come this year. We increased our rates to try and brace for it, not knowing what the true impact would be, well it didn't happen. So, we received a surplus because we had increased our rates. It didn't happen in 1999 and it didn't happen in 2000, it Meridian City Pre-Council Meeting Apri119,2005 Page 7 of 21 didn't happen in 2001. Well, it happened in 2002 and our projections were fairly accurate from what had occurred. So, we have lived off of that surplus for 2002, 2003, 2004 and 2005 and now that surplus went up and now it's pretty much back to gone. That's the issue that we are facing here is now where do we go from here? We (inaudible) slower expansion, nobody realizes that than the City of Meridian. Should have had an ambulance out here a long time ago. But, with this funding crisis looming, there was hesitancy to do so. The implemented system restructuring, we certainly have encouraged the co-Iocation, worked with that, we have redeployed our staff, increased our volunteer force and done whatever we can to try to save cost. Commissioner Judy Peavy-Derr has gone back to Washington, D.C. on three different occasions to speak with our federal delegates to see if we can get some type of relief from the federal level. In our opinion this is an unfunded federal mandate, but unfortunately we are having to pay the brunt of it We also have had the state legislative action. We were in the legislator in the last two years and unsuccessfully - tried to get a bill passed that would allow the district to go to the vote of the people with a permanent levy increase with the super majority vote, which was the same thing like the fire districts have and library districts and so forth. We were unsuccessful for the first two years and we finally got it passed this year. So, that is now on the books. They also commissioned the Blue Ribbon task force to citizens to look at all this type of thing and really the unanimous recommendation that came from this is some type of taxpayer support is going to be necessary. Mr. Alloway can certaînly speak to that, however, they looked at a couple of different options of doing that, but realized that from a fee for service aspect we are not going to get there, so further tax support is probably necessary and the EMS Advisory Board, which is also a citizens group that advises us and we meet on a monthly basis, went through that thing and came up with the same recommendations. They went through the Blue Ribbon Task Force and certainly concurred with their decision there. So, the Blue Ribbon Task Force there were a couple - there were 16 different recommendations they did, you know, they have implemented the cost saving ones and certainly some of them will take longer as we are working through the EMS planning and coordination committee to implement, but that we are working on all the different aspects of that. One of the options was the over-ride levy, which was a two-year levy adjustment. It wasn't the Blue Ribbon's first choice and the reason for that was that it was a short-term fix for a permanent problem. They don't see this problem going away. So, they said why - we don't want to spend a great deal of effort because you also have the cost of an election. This election is going to cost the commissioners about $100,000 to put on and they said why do we want to do that for a short-term fix? That was kind of the thinking of the Blue Ribbon Task Force and so their second option was the redistricting thing that the Blue Ribbon Task Force unanimously endorsed at the time as to dissolve the current district and re-establish at another one at a new rate and that is what Jerome County had done, so there was precedent in doing so and anyway that was the range. Thai's not where it would have necessarily been set, but that was the range. The commissioners had their public hearing, they received lots of input from many different entities and Meridian City Pre-Council Meeting April 19.2005 Page 8 of 21 individuals and decided nobody wanted to do this without a vote of the people. That was never our intent, we want the community support prior to this going into effect, this law that we just got passed, there was no mechanism in Idaho Code to go to the vote of the people for a permanent fIX. The Commissioners originally were looking at a permanent fix, without doing so now we are with a temporary fix, but it does bring it to the vote of the people, which certainly no way you can disagree with. So what would the over ride accomplish? They will make up the Medicare loss for the next two years. That's all we are looking for is the money that we are going to lose out of Medicare, if we could have that back then at least we could continue our operations at the current level of service and it certainly will help us assist in developing our comprehensive EMS system as we are working to the EMS planning and coordination committee...., that's going to take time and this will help maintain the level of service while we go through that whole process and look at different options of an EMS structure and system and is there a better way to do it. That will certainly be evaluated. For the over ride election and this out of a (inaudible) office, it's a county election, so unfortunately or fortunately depending on your perspective, it's good for the people, all 125 precincts need to be open because it is a county election, however, that is very costly and the time is May 24111 and you can see the other (inaudible) by mail or at Barrister, but the cost is going to be approximately $100,000 to open all 125 precincts for the day. That's just Dave Navarro's estimations of costs. So, what they are asking for is $4.8 million to cover Medicare losses only and that is just for the next two years, so if you recall back from the chart that we said we are estimating right around $2.35 million for fiscal year '06, $2.45 million approximately for '07 and that's those two years and you add them together. It's not asking to balance the budget, it's not asking to increase services or program, ifs basically make up for Medicare losses and we will continue to work on efficiencies through cooperation, consolidations, partnership efforts to see whatever we can do to make up the remaining of the cost, but let's just try to fund the Medicare loss so we don't have to redo services and to be successful it's 50 percent plus more. So the over ride then, what happens? I just kind of got into that a little bit. We had the planning and coordination committee up and running, which all the area fire chiefs, the hospitals, physicians and EMS are all represented, all getting together at the same table and saying what can we do? W1atever happens out of that committee is going to take time to implement. What this over ride will do is give us two years so we are not in an EMS crisis and by all of sudden having to reduce ambulances or do anything drastic like that as we work through this process over the course of the next two years. Even if there was a consolidation effort, historically a consolidation effort takes five to seven years of anyone that's ever done it. So, anything that we do it's going to take time. This over ride election will buy us some time. So, our goal for Ada County is to provide the most effective, clinically sophisticated, efficient EMS system that we can and to every citizen in Ada County. That's very important to us is that right now we deliver a countywide EMS delivery system. We think that fragmentation would both increase cost and potentially decrease the level of care that's being provided because it would be different and what we don't want is Meridian City Pre-Council Meeting April 19,2005 Page 9 of21 many different systems operating within the county when by common sense would say that one system, one consolidated type system would certainly be more efficient just by (inaudible) pure economy of scale. So, in summary, Ada County is committed to being (inaudible) in the county wide EMS system and to maintain that high quality that we also know the fiscal responsibility that has to be to pay for that system. Current tiered system works. It works very, very well. To get the high of cardiac arrest survivability rate, you can't do that with a bad system. As Ada County continues to grow we must grow with it. We can't ignore that fact and I am thinking ahead and this is really a funding issue. The system works, it's just they changed the funding rules on us and now we are trying to figure out how to adapt that system. It's not a necessary of systems or it's not necessarily a political issue, it's really been working and it's been working very well for 30 years, we just need to figure out how to fund it, which is the idea behind the over ride. That is my presentation. So, I would be happy to entertain any questions. Wardle: Council, do you have any questions? Donnell: Yes, Mr. President. Wardle: Ms. Donnell. Donnell: Troy, if you knew the rule was going to change in 1999 and you put in the fee increase, would that not have been and you knew that was coming, obviously, would that not have given the time from then until the rule did change for you to do what you are proposing to do with a two year - an over ride supported that will give you two years to do this coordination, this planning? Would that not have been the time to do that? Hagen: Again, not really knowing what the impact was going to be, it would have been very likely that the impact would of, could have been minimal and that we would have been able to function and to continue to grow and continue to expand. Up until the rule change, the EMS system functioned very well and we were able to keep up with growth. We were able to move in that direction and do those things. I think the question as - we certainly wouldn't have gone for an over ride because we had no idea what the impact was and we were adequately funded at the time and so just not knowing what that true rule was and I think that actually we have - you know as - even our oo-Iocation aspect shows no aid, we only owned one station so we do partner, we run very. efficiently and very lean and the system worked. We didn't see that this was an issue that would - you know we didn't think it would be as significant as it was or we were hoping it wouldn't be. Donnell: So, follow up, Mr. President. Wardle: Sure, Ms. Donnell. Meridian City Pre-Council Meeting April 19, 2005 Page 10 of 21 Donnell: So, let me phrase that again maybe a little bit differently. I hear you say that you didn't think that it would be as significant and yet from the time you raised the fees until the rule went into effect and you have been living on the surplus from those fees, would this not have been the time for this kind of coordinated planning that you are assuming will occur if the over ride passes and it gives you two years before you'd have to run the over ride again, is that right? Hagen: Mr. President, I am sorry if I didn't answer your question the first time around. I am trying to understand exactly should we have done it back in 1999? Yes, very likely. If we had known that this was going to be this way, absolutely. What we were also looking for was - that's why we went to the legislature for two years, a Blue Ribbon Task Force is this issue has been studied and studied and studied and yeah, if I would have been in charge, if I could have done anything differently we would have been able to take action on this long ago, but we tried all these different options and all these different things that we studied extensively and how we have gone to the legislature again, two years that failed. We were looking at many different types of fixes verses having to just go into and say okay everybody, we are going to completely change the structure because as I said the structure seemed to work well. Donnell: Okay, then follow up again. Wardle: Sure, Ms. Donnell. Donnell: So, let's just take this out a couple of years. Let's say that the over ride is successful and it's a two year over ride and it generates the funds that you need to continue the operation at the level that it is currently and also gives you the time to do the planning to see what we are going to do in the next two years, right? I mean after those two years go. When that over ride culminates, I don't know a better word there, ceases whatever, no longer the funds are there, then the tactic will be of course to go to the people saying that if you don't pass this over ride again, then we are going to have to cut services back, right? Because we will have maintained a level of service for these two years on an over ride because an over ride is short term, so what do you expect that we would accomplish with this? I guess I am having a hard time having known that over rides are in deed short term fixes. Hagen: Mr. President, Councilmember Donnell I am hoping and optimistic that our EMS planning coordination committee will figure out how we can throw out all of our resources into and onto the table and hopefully reduce the entire cost of both the fire and the EMS system since we are talking about you know throwing everything out onto the table is how can we reduce the overall cost? And those are the things that we are going to - you know that every body had to come to the table to be able to do and so it's not just - I don't think this is an EMS issue we are talking EMS planning and coordination it's also the fire issue and okay Meridian City Pre-Council Meeting Apn119,2005 Page 11 of21 everyone has resources, let's throw everything out on the table and leI's see what we can come up with. Donnell: And perhaps a health care issue as well. Hagen: II's absolutely a health care issue. There is no doubt about that. Donnell: Which you can't fix. Hagen: I can't fix that and certainly thaI's not going to be fixed within the next two years. De Weerd: Mr. President. Wardle: Madame Mayor. De Weerd: I guess also this two years gives us time to work in collaboration with all of the providers, but they did change the legislation so they can go to the voters at that time for a permanent fix. They wouldn't have to come back every two years for a temporary one? Donnell: Is that right? De Weerd: The legislation just passed with the support of the Fire Chief's Association. Donnell: So, just for clarification when I was listening to you saying that the legislation passed, I was assuming that that legislation was that you could go to the public for an over ride. That's not the case? It's a permanent over ride is what that does? Hagen: Mr. President, Councilmember Donnell currently on state statute even before we just got this rule passed, we could do an over ride. That is what we are going for. We are going for a temporary over ride in May. The new rule did exactly as the Mayor indicated, it gives us the ability to go and fix it permanently with the super majority vote. Now a question may come up why not go for that now? We believe we need to go through this process to get the support of everybody to get a super majority. Wardle: Chief any questions at this time? Anderson: Yes, I guess being the new comer going back to Ada County, I can plead ignorance on a lot of this stuff, Troy, because I don't understand all the history of it and I am trying to get a grasp on it. Can you explain, I guess, why did Medicare make these changes in the rules in the first place? I mean what was the intent there? What were they trying to do? Meridian City Pre-Council Meeting April 19, 2005 Page 12 of 21 Hagen: Chief, Mr. President, Council good question. It actually there was good intentions behind the bill. It was - we had Medicare population on a fixed income and they didn't want to see all of them being medically bankrupt because they had a health care issue and so they came through and said if you are on Medicare and it's also to control their Medicare costs at a federal program, this is all you are going to get. We are going to establish a national fee schedule. This is not just an Ada County issue this is happening all across the country. The ones that are hit the worst are the ones that are so reliant on fee for service. Now those that were very heavily taxed based probably had very little impact from this rule. Those of us that were reliant on the fee for service, impact was significant, but that was the idea behind it was to protect the income of those that are on a set income. So, there is obviously a very powerful lobbying force and the other part of the lobbying force would be the insurance companies. As I mentioned, we can't go back and bill our secondary insurances even. They even took that ability away, so I am sure there was quite an extensive lobbying effort on the part of the insurance companies to make sure that this bill passed as well. Anderson: I guess just a follow up comment I guess on how I view those Medicare changes. I mean it's kind of like, Councilmember Donnell talked about you know the health care cost in general. It seems to me like those Medicare I Medicaid changes came down because of the spiraling health cost and the federal government said we can't continue to charge this much for ambulance services and for ambulance fees and they were in effect when you said it was a federal mandate, they were setting a limit saying this is the maximum that you can charge and you need to streamline or whatever you need to do, restructure it to become more efficient at providing that service, I guess is kind of how I read that too and we may have a difference, I guess, in opinion about how that comes down. But I guess I am seeing that we need to do something to become more efficient at how we deliver those services. If we look at how the private sector would deal with something like that Hagen: Chief and Mr. President, I agree. However, when they set the cost the vendors didn't pay attention and neither did the inflation index. They didn't pay attention either. I think you know where we need to - you know what we are trying to do is we are certainly trying to be more efficient as we go because there is no choice, but ambulance services is really funded by two different things. It's fee for service and it's taxed based. If you take away such a large margin of your fee for selVice, you either are going to have a significant reduction in service, how the private enterprise deal with this is that they would manufacture less (inaudible) or they hang up the sign that's next to the billing office window that says we accept only 10 percent Medicare patients. We can't do that being a governmental 911 agency. We accept everybody. We accept 100 percent patients if that's all that calls us. So, we don't have the ability to put the limits on like the private enterprise does. Meridian City Pre-Council Meeting April 19, 2005 Page 13 of 21 Anderson: Also on one of your slides where you were talking about things that have been done. You talked about that you raised fees in 1999 and you say you slowed expansion, again, not having the history could you tell me what expansion has occurred since 1999 so that I could kind of compare that? Hagen: Very little expansion had occurred up until the last year. In the last year I have made more of a determination that there is also a balance there. We could continue to say that we are not going to provide this service because of cost issues - and let the patient care suffer and public safety be at risk or we can get it up to the level that is acceptable, since the county has a statutory obligation to provide an ambulance service - is that we need to be able to provide the service and provide it adequately and say this is a funding issue - let's go and say this is a funding issue and let's get the funding fixed, but we can't just not let the service be provided. Anderson: From what I can gather attending meetings, when you say the expansion has slowed, but Meridian just recently received an ambulance out at Ten Mile Station and Kuna got one about a year ago. When did Eagle get theirs? Hagen: 1999. Anderson: So, we have added some additional ambulances or cars? Is that the correct terminology out into the communities? Hagen: Just in the last year. Anderson: Okay and then I have been hearing something about a Hollandale Station in some of these meetings. Could you explain for me what is the Hollandale Station? Hagen: Certainly, Mr. President, Council. The Holiandale Station is Boise Fire is vacating the Whitney Fire Station that sits on Overland Road and they are building a new station on south Five Mile and Hollandale and our station will go away. We currently own a small manufactured home out in the back lot behind the Whitney Fire Station, so it's not like we are living high on the hog here - that's the station that we have had for many years behind there. They are selling that property. So, the offer by Boise Fire was you can move into our station with us, but we are asking you for $300,000 to do so. It's a matter of making the station go away, which would certainly impact our response times and our capabilities out into southwest Boise or to go in there. If we try to go and build a stand along station it certainly is going to cost more than $300,000. Anderson: So, that Holiandale Station would be your proportionate share of joint facility with Boise Fire? Meridian City Pre-Council Meeting April 19, 2005 Page 14 of21 Hagen: That is correct. It's a $1.7 million station. They are asking us for $300,000 and it's a movement of one station to moving it down the road basically. Anderson: You also indicated that when you were talking you said our surplus is pretty much nothing. What is your surplus right now? Hagen: At the end of this year, we anticipate it will be about $450,000 remaining and that would be utilizing $2.3 million out of our surplus this year. That is the balance that would be remaining or should be rolled into next year. That is out of a $9.5 million budget, it's not a lot when we needed $2.3 million to budget of that to utilize this year to balance our budget. So, you can see there is already a $2 million hit right there that we won't have available next year's budget. Anderson: Just a couple more questions here. You indicated that there was 16 recommendations that came from the Blue Ribbon panel and that you had implemented all of the cost saving ones. So, how many of those 16 are implemented then? How many were cost savings? Hagen: I don't have that right in front of me, but again it was co-location was a part of that. The Blue Ribbon Task Force recommendations were more of the system issues that we were addressing in the EMS Planning and Coordination Committee, so co-Iocation being one of those with Meridian and the ones in Boise that we have done since that time. At one time, as you know, we were entertaining property at rf' and Cherry. That was one of the things that (inaudible) it says okay we are going to co-Iocate rather than try to purchase a stand alone station, so that was one of them. There were some of the other (inaudible) I am sorry I don't have them in front of me, so I'd have to go back through, but the ones that (inaudible -) at immediate cost, we are working on and implementing - Wardle: Troy and Chief just to let you know we also invited Don Alloway from the Blue Ribbon Task Force to speak in just a moment to some of those issues. Anderson: You had indicated that a consolidation could take five to seven years to acoomplish because that's typically what it's taken in other areas and I guess just kind of an observation that I have had in the meetings that I have attended so far, there doesn't seem to be, I guess, I am not seeing that spirit of cooperation that we are going to do consolidation. I mean, there seems to be a lot of posturing and a lot of rhetoric back and forth about firemen can't make good paramedics, the system works great now, we would saturate the market with paramedics if we added paramedics to any other agencies besides fire. I guess, my question is are we just going through the motions or is there a sincere effort to do some type of consolidation because, I guess, back to the original comment I made about how I view the Medicare and Medicaid cuts, we need to become more streamlined to become more efficient, but I am not seeing, I guess, Meridian City Pre-Council Meeting April 19,2005 Page 15 of 21 from the meetings that spirit of cooperation that you are talking about. It seems to be that everybody is just saying why it won't work and why we can't consolidate. Hagen: Chief, Mr. President, Council I think we are so early in this process - we need to get that out of the way for some of it because we had been talking all funding so far. This last meeting was we had just starting determining metrics and if you recall my comments it wasn't that you can't have a good paramedic and fire agency, I know lots of good fire based EMS systems. My point is there is a set number of paramedics in the entire system to include Fire Department, Paramedics, however, there is a set number that there should be and whether thafs half of them here or half of them are there, but there is a core of competency or a core group. That has been my point all along. I have nothing opposed to fire-based EMS, there just needs to be a system. We have eight public safety entities that are involved in this process. When I say five to seven years to consolidate, it's usually a city Fire Department and a city EMS Department that are consolidating and that takes that long. We are talking about eight different political entities. This is not going to be an easy road. You certainly have my sincere efforts to be able to do whatever we can do to make this work and yeah, I think you have it from the county, but again there is also seven fire districts to be able to do the same thing. De Weerd: Mr. President. Wardle: Madame Mayor. De Weerd: (inaudible-) saying the presentation I participated in at the Meridian Chamber of Commerce, this carne up. I don't if it was during the meeting or after the meeting, but I don't think the consolidation was necessarily merging two into one. Irs more looking at better efficiencies and using the one medical doctor and the medical training, which the Commissioners and the different entities have talked about and seem to be in agreement on, it would be something like that. We also talked about Meridian moving into the paramedic J firefighter realm and using that as an opportunity to set a model that can be looked at and developed that could show how it could be done and those kind of things. I guess those are the kind of commitments that we are looking for and not necessarily that everyone would go away and there would be one entity. It's more how we can gain efficiencies and collaborative efforts, those kinds of things. I believe definitely that the group that has been created can find those lines and I guess I would say that Meridian could be an excellent model of opportunity to, like I said, to show how those could be accomplished. Anderson: I agree wholeheartedly, Madame Mayor and I guess one of the things that I have learned in the two weeks that I have been here is that I have been told under no uncertain circumstances by Council members and the Rural Fire District that I am to put paramedic (inaudible) company program together and so Meridian City Pre-Council Meeting Aprí119,2005 Page 16 of 21 I guess while I have you here and we are talking about that EMS system, I guess, I would ask what kind of support we could expect to receive from your agency, Troy, as we move down that road. Hagen: Mr. President, Council aside from the funding issue, obviously, we - our whole issue is the entire system and trying to make sure that the coverage is adequate, is good, competent and so forth. We just don't want to see it decrease in the level of care. I am not opposed to Meridian putting on paramedics. I am not opposed to Boise putting on paramedics. I will bring that right out front. What my concern is is that we don't flood the system with paramedics because more paramedics are not always better. You know there is lots of research that really is just now coming out that ifs not always the best thing. My whole point is if we are going to do it, let's make sure we do it right and by doing it right we are doing it together. Throughout the entire Blue Ribbon Task Force, Dennis Johnson representing the fire agencies came in and said fire has a resource, EMS has the expertise. I am offering you our expertise as to be able to go forth and do this. Our training aspects of it are how we build the system and how we work it. We need to all work together to be able to do this because I agree, if you have the resources we do have the expertise, we are going to be able to build a better system, but we need to be able to do that and ifs not like everybody is going to agree on how we get there - I am not that naïve, but that is our goal. Wardle: Thank you, Troy. Mindful of our time, I am going to ask you to stay around for just a moment and invite Don Alloway with the Blue Ribbon Task Force to come for a couple of comments. Alloway: Thank you Mr. President, Mayor, Council members I am Don Alloway. I served as the Chairman of the Blue Ribbon Task Force put together by the County Commission to look into Ada County EMS and the thing that caused them to create the Task Force was the Medicare funding problem, but they instructed us that everything was on the table and we should look at the system in general. So we not only addressed funding problem, we addressed a number of other issues and there are a lot of numbers that come around and one of the things that we recommended was that we dissolve the taxing district and create a new one because under the law two years ago, that was the only way to permanently solve the funding. The County Commissioners came out with a recommendation that they would do that and they would set the new levy rate at 4 mills and we are at 1.227 mills now and as a result of that in my testimony in front of the County Commissioners, I said that the absolute, outside maximum that they should set out was 2.5, not 4 and they should only set it at 2.5 provided that Ada County EMS looks seriously at all of the 16 recommendations and the implement of those. I think that one of the problems that we run into is the numbers taken out of context can give us some strange outcomes and I certainly didn't mean to imply, nor did I ever say that it took 2.5 mills to fund a competent EMS system because I never believed that. Your new Fire Chief indicated that after only two weeks he was concerned that there wasn't the spirit of cooperation Meridian City Pre-Council Meeting April 19, 2005 Page 17 of 21 to implement the 16 recommendations of the Task Force. As a matter of Paul Anderson with BSU in 1999 came out with the report that listed. a number of things that EMS should do and- (tape turned over) Alloway: - the Task Force was called, EMS said that they had reviewed the report and responded to every one of those criticisms. Our 16 recommendations from the Task Force were very, very similar to the recommendations of Paul Anderson and we didn't read that report before we made those recommendations, so even though that it was alleged that they had all been addressed, they really weren't Your new Fire Chief in two weeks has figured out that we have still a turf battle - empires that might be (inaudible) if things happened. There are some things that are pretty simple and straightforward. In 2002 when we started the Task Force, we had seven ambulances in Ada County and on a given business day there were seven supervisors on duty at Ada County EMS. Ada County EMS has a higher personnel cost per call than most ambulance districts because they appear top heavy and one of their recommendations that we echoed what Paul Anderson said is that we need an independent group that understands the operation of ambulance districts to come in and review the operations in depth. This is to make sure that the Task Force didn't overlook something about running an ambulance and service that you needed a level of supervision that high. They had six ambulances that were just sitting around and that they weren't using it. They daimed they needed them for mechanical repairs. We didn't think so. We thought they were spares and they could give them to some of the Fire Departments and let the Fire Departments run them in the low call areas to give better service because we are taking 20 and 30 minutes for ambulances to show up in some areas and by the way, some parts of the county that is never going to improve. Overall we felt EMS did a good job, but we felt that there was a lot there that could be changed. In the period of time subsequent to that between now and then they have increased the number of supervisors. They have increased their operating budget by almost a million dollars and at the time that Ada County EMS was being looked at by the Task Force, their budget shortfall is a result in part with the Medicaid and Medicare was about $1.3 or $1.4 million. The numbers that were on the slides would lead you to believe that they are losing $2.4 million in revenue and I guess technically that is correct, but they only collect about 60 percent of what they bill and their ambulance rates are set to be able to break even at that 60 percent collections so they don't need that $2.4 million to make up for Medicare, they need maybe a $1.3 million or $1.4 million of it and so were it just to make up for Medicare and whatever level of operating and efficiencies were (inaudible-) close the year 2002 an over ride levy that would create $1.5. million each year for the two years would be adequate to give them adequate funding. This levy that creates $4.8 million or $2.4 million a year over the next two years is what they need at their current level of efficiency with operating expenses a million dollars more than it was two years ago. There were a number of things that to me are Meridian City Pre-Council Meeting April 19, 2005 Page 18 af21 no-brainers. There are calls that the dispatch system ranks the calls according to what's wrong. There is a series of questions that the operator asks the person that calls in - you know, is the patient breathing and a number of things like that to determine exactly how serious it is. There are a lot of calls that fall into category where they are not life threatening. Maybe somebody has a broken leg, ifs going to hurt like the devil, but you are not going to die of a broken leg if the bone isn't sticking out and they are not bleeding. If the ambulance gets there in a half hour that is going to be fine. Those are called alpha calls and there are about 4,000 to 5,000 of those calls every year. If they would dispatch the Fire Department only and not the ambulances,remember we have got 27 fire stations and 10 or 12 ambulance stations depending on how you want to count them. If they would just dispatch the Fire Department, most of those, 80 percent of those calls are never transported anyway, that's a substantial savings, more importantly it makes availability better for the ambulances, which would get response times up. That's a simple thing, the technology is there - they know about the calls, but ifs a turf war. The Fire Department wants to be dispatched on all the calls, I am told, because they like the high numbers to justify their existence. Frankly, the ambulance service wants the same thing and so we are dispatching a white truck and a red truck for a lady that is in a wheel chair and has fallen out of the wheel chair and she is perfectly fine on the floor, but she can't get up by herself and we send those two trucks and that's part of the savings. We could quickly look at the structure and get rid of over supervision if in fact, we have it on an interim basis and save substantially in personnel. We could put a hiring freeze on it and save - a lot of things like that they we could do that we haven't looked at. It bothers me that now Ada County EMS has said that they have addressed or are addressing all of the Task Force recommendations and yet I think that if you would have another committee look at Ada County EMS again, you would find that Paul Anderson's problems that he showed and the Task Force problems that they showed are still out there. They need some funding in order to stay in business and we need ambulances and so we need to provide them with that funding. If we provide them at the funding on the levy level, we are going to be providing them with funding where they can operate at their current -under their current steam of operation comfortably. That doesn't guarantee us change and it leaves it at status quo. On the other hand, if we vote the levy down, they are not going to have enough money to operate under any scenario, so it's a tough thing that you are going to face as to whether - as to a political body you want to support this levy election or if you want to say don't waste your money on it, ifs a problem that is not going to be cured that way- complacency is going to set in and you need to talk to your Fire Chief and the previous Fire Chief about the conversations that have gone on since January as this committee has been meeting. You need to look at the numerous indications of cooperation and non-cooperation. I am concerned about Ada County EMS willingly allowing Fire Departments to have paramedics, frankly. Kuna right now has an ambulance. They have paramedics. Ada County EMS will not let them transport. They have what they call a chase car, which is a Chevy Suburban with a paramedic in it. When they go on a call, if they need transport they park the Meridian City Pre-CouncH Meeting April 19, 2005 Page 19 of 21 Chevy Suburban at the scene, the paramedic gets in the ambulance and they transport in the Fire Department then if they have enough man - drive it back it, if not they call a volunteer fireman to go out and do it. That chase car costs $450,000 a year. Kuna said if they could be supplemented in funding by $75,000 a year or $80,000 a year they would just run the ambulance - been turned down for doing that and that's not the spirit of cooperation that I expected to see. We could put an ambulance in Starr the same way if you just give them an ambulance that's one of the six surplus ones they had they would .furnish the paramedics and they would be happy to do it and that wasn't done. Those are the kinds of things that may be in a perfect world with all of the money in the world, you might not want to do, but we might want to do as citizens of Ada County and we have got to tackle those problems. So, the question, I think that's before you is not whether $2.5 million is needed because it "an isn't needed in a well run ambulance in my opinion, but "bn it is needed with our system that we have now and the system hasn't changed and so in the short run they need money. The question that is in front of you is if you support the levy is it going to reduce your ability as a political body to encourage the County Commission to revise and revamp Ada County EMS so that they are substantially more efficient and more cooperative with the other public safety agencies and if supporting the levy gets that support, then you ought to publicly support it. If on the other hand, publicly opposing the levy as the City of Boise apparenity has chosen to do, we'll give you the leverage to force them to do that by bringing it to a head earlier then I think you would want to do that. It's a decision that I am not sure how I would vote - we are on your side and fortunately you have a week or two to make your minds up. But, it's a tough one because I as a private citizen and having the experience of some sixty hours of public testimony and several hundred hours of reading and research during the Task Force I am convinced that we are wasting money because we are not willing to allow Fire Departments to participate in the EMS system and there are a lot of things out there that can be streamlined and made much more efficient, but I am not convinced that I knoW enough to get how to get it to happen in Ada County right now with the political sweat that we have and so lam afraid I can give you some information that's my opinion and mine alone, it's not the committees opinion and I can point a problem out to you and I am also afraid I can't help you at all to make the decision because it's a really tough one. We have a system that needs more money, but they also need change and you somehow have got to figure out how to do both and do both more sufficiently and I can only wish you good luck in that. I would stand for any questions that you have. Bird: Mr. President. Wardle: Mr. Bird. Bird: Mr. Alloway in your opinion, after all the hours that you guys in the Task Force did and I appreciate, what do you feel is what they need in a two-year levy? Meridian City Pre-Council Meeting April 19,2005 Page 20 of 21 Alloway: If they reversed some of the management decisions made in the last six or eight months they could get by on approximately $3 million over the two years. They would have to do some belt tightening and rotting and there would be some gnashing of teeth and screaming and hollering, but we would not suffer from an ambulance response time, I believe if they took that step. Bird: Mr. President, follow up. Wardle: Mr. Bird. Bird: Coming from a city that tightens their belt all the time, our employees and stuff, I happen to agree with you on that deal. I think that everybody could definitely be more efficient and I think that Task Force 16 points, I don't believe is being adhered to at all. Rountree: Mr. President Wardle: Mr. Rountree. Rountree: Mr. Alloway and I am going to ask you for probably a pretty frank observation on your part, but having worked this issue, the hours you worked it, you mentioned that there are issues in terms of cooperation and turf wars and those sorts of things. Is that primarily being driven by the staffs of the emergency services' public staffs and public services or is it being driven from the elected officials down? Alloway: Mr. President, Councilman Rountree it's a guess and please - Rountree: Just asking for an observation. Alloway: As an observation, I think that over time because of the management philosophy in Ada County EMS there has developed an aura or a feeling that only they can do things that nobody else can do it quite as good as them and quite frankly this is not unique to Ada County EMS, Boise City has Firefighter's Union and the firefighters have come out publicly and stated that they can run a better system than Ada County EMS and thafs part of the same thing. I think- but at the same time, public officials when they see this happening ought to be jumping on management with both feet and that's never happened. Rountree: Thank you. Wardle: Thank you very much, Council. I would like to thank Mr. Alloway and Mr. Hagen for coming to join us and note that also the rural fire commission is here. We have some decisions to make and we have got some resources and I believe that the Clerk's Office has everyone's numbers if you would like to Meridian City Pre-Council Meeting April 19, 2005 Page 21 of 21 engage in further conversation and begin the discussion. With that I would entertain a motion to adjourn. Rountree: So moved. Bird: Second. Wardle: Irs been moved and seconded to adjourn the meeting. All in favor? ALL AYES. MOTION CARRIED. MEETING ADJOURNED AT 7:05 P.M. (TAPE ON FILE OF THESE PROCEEDINGS) APPROVED: ~ as I 24 I as DATE APPROVED ATTESTED: