In a well attended special meeting called by the Tucker County Commission, J. R. Henry Consulting presented its findings and recommendations to the ambulance authority board and the county commissioners.
Commissioner Rosenau stated in opening, “What we the commission have done is hired J.R. Henry Consulting to help us and the EMS have a different set of eyes in looking at our process in Tucker County to see if there is any improvements we can make.” Rosenau went on to say that J.R.Henry had completed an organizational assessment and were present to explain their findings to the EMS board, commission, and the public.
J.R. Henry opened by saying, “We have the privilege of working with large, small, and rural ambulance services all across the country. It was a pleasure working with all of your staff and Sheila (Marsh) here in Tucker County. They were very forthcoming and cooperative with the information, and you have a good EMS system. But, you also have the same kind of issues and concerns that a lot of other rural systems have.” Henry went on to say, “Some of these issues that we are going to highlight for you today have to do with finances, lack of volunteers (like we used to have years ago), increased training standards and a variety of things.” Henry added, “Everyone here should be commended, including Sheila (Marsh) for her leadership and management of the organization. It’s not any easy organization to run.”
Henry went on to give an overview of the report stating that questions would be welcomed and that this is the end of phase one of the consulting project.
The consultation consisted of an on-site assessment on January 8, 2014 (which included interviews and data collection with administrative staff), contact with the Tucker County 911 and MCA (the EMS billing contractor) to obtain additional call volume and other applicable data.
The report took into consideration the large land area of the county with the relatively small residential/commercial development with the majority of the county (roughly 95 percent) being agricultural, wildland, or undeveloped. These factors combined with the closest hospital being in either Elkins or Oakland causes the typical EMS turnaround times (call received, dispatched, arrive, assess/treat the patient and transport) to be between 1.5 and 2.5 hours.
Henry noted that the employees prior to 2013 had not received pay increases for four years and that even with the raises in 2013 (which were possible due to the $116,000 and $84,000 subsidies provided by the county commission) they were still underpaid in regards to surrounding counties. “Our goal here was to try and find recommendations for you, where we could minimize expenses on some parts of the operation, so you could re-invest in the employees,” Henry said.
The study also shows that the budget is about $1 million, with the major revenue sources coming from subsidies from the county commission and billing fees of $833,530. However, with regard to billing, no treatment can be billed to an insurance company unless a patient is transported. Everytime the ambulance goes out the door it costs approximately $940.63 .Therefore, the minimum billing for every single call needs to be approximately $1,000 to break even. Currently a patient is billed $150 personally, if an ambulance responds and the person refuses transport. It should be noted that TCEMS collection percentages are at 51 percent which is considered “above average” in comparison with EMS services with similar call volume. Even so, the net loss for last year was $37,000, which is typical for other rural EMS providers.
Henry went on to state that Tucker County is located in a “Super Rural” area by Medicare. As such, it receives a 23% bonus on all reimbursement for billed basic rates and that unless congress does something to extend this bonus, it will expire on April 1, 2014. This could result in significant decreases in future Medicare reimbursements. Upon hearing this, Commissioner Rosenau urged the board to contact our U.S. representatives and senators to extend the regulation for this super rural bonus.
Henry stated that they were unable to verify during their assessment if a trip sheet had been generated for every call and suggested that the administrative office be tweaked to make sure that every call has the PCR (patient care report). Sheila Marsh stated, “This has been addressed and someone is working on this two days a week to make sure all run forms are entered into the computer and all documentation is complete.”
This report identified other areas of concern including the size of the fleet and the staffing. The TCEMS are only about 30 percent productive, due to the low call volume, only about 1,200 calls per year.
This means transporting patients. At this time, the average number of calls per day is between two and four. So an ambulance is only on the road 25 percent of the time. So a large amount of non-revenue work is done at the stations in keeping equipment stocked and the ambulances ready.
Recommendations were made to cut the fleet from 5 vehicles to 3. This would save money on insurance and equipment needed to stock the unit. It was suggested that scheduling and other changes should assure minimum staffing of one ALS crew, 24 hours a day, 7 days a week and look at possibly reducing the second crew from a twelve hour shift, four days a week, to an eight hour shift. Henry stated, “The worst thing you could do right now, would be to add more paid staff.” He also suggested scheduling an employee meeting to discuss the implementation of a new on-call scheduling process to provide back up staffing when call volume peaks. The use of a web based scheduling program was suggested. Additionally, it was recommended that a new system of volunteers be utilized to fill staffing gaps as they had been in the past. At this time, no volunteers are being utilized, all EMS members are compensated employees.
The use of volunteers was met with some dissension, as in the past, it had not worked effectively. Bobby Phillips stated that in the past it was difficult to get any volunteers to respond unless it was a motor vehicle accident and that the volunteer system just did not work. Director Marsh stated that this had just been revisited in 2008 and these people are still on the roster and are not giving any time.
Commissioner Diane Hinkle stated, “We have willing volunteers on the mountain. who are ready and willing to make calls. We have to utilize them.”
Rosenau stated, “Not only on the mountain, but the entire county. I hate divisions in the county.”
Hinkle added, “I absolutely believe that we should use volunteers county wide, but we absolutely have to do something on the mountain to address the shortage of coverage up there.” Hinkle went on to add that this would be especially necessary if the crew up there is to be reduced.
Mitchell Beall added, “The reality of the geographic situation is that there is an ambulance 24/7 in Parsons period and the mountain does not have an ambulance 24/7. I realize that we do not have the funds to man another unit on the mountain. But then, we have to look at the reality of, if you don’t want divisions, then we have to have the available resources for those people. It is not that anybody has anything against the people in Parsons or the people on the mountain. It is simply the matter of having to choose whether it makes more sense to drive 35 minutes to the hospital or waiting for 35 minutes to get on the scene. In reality the people on the mountain have to ask, am I going to drive myself.”
Phobe Mollard stated, “I chose to drive myself to the hospital when having chest pains. I had to pull over and let my elderly mother drive, because I knew a crew would not arrive at my home in time.” Mitchell added, “You’re saying volunteers don’t work. Well, you could set up a volunteer station and the volunteers sign up for a four hour shift and they are obligated to respond during that time. It could work.”
Another item suggested was a system approach to rapid response which would encourage the participation of first responders such as law enforcement, fire personnel, 911, EMS, and perhaps even a trained EMT with a jump kit at their home that could be on the scene, possibly before an ambulance can arrive. Identifying the best practical use of these combined resources could greatly enhance the level of care in a more cost effective manner. The use of sharing the assets of surrounding counties be considered.
Henry stated that this report is just a guideline for the EMS to look at and try some new ideas going forward. Rosenau added, “Change is hard.”
In conclusion, it was suggested that the ambulance authority take this report and study it. Consider all weaknesses that were identified and look at the proposed recommendations and come up with a plan of action that would include new solutions that will address the need to cut expenses and still effectively serve the patients.
Those attending included commissioners: Diane Hinkle, Lowell Moore, Michael Rosenau; Prosecuting Attorney: Ray LaMora; County Clerk: Sherry Simmons; Ambulance Authority Board: Bobby Phillips , Kathy Kahler, Sheila Marsh, Shayna Burdock ; J.R. Henry Consulting: J. R. Henry, Mel Musulin; Tucker County Convention and Visitors Bureau and Chamber of Commerce: Bill Smith; Canaan Valley VFD: Mitchell Beall; Parsons VFD: Tom Klus; Attorney Pat Nichols, Tucker 911: Judy Long; concerned citizens Joseph Strait, James Mollard, Phoebe Mollard, , TCEMS: Steven Mitchell; and Joel Goughnour.
The entire Organizational Assessment report may be viewed online at the Tucker County Commissions website.