Report Prepared by: Derek Parker, Fire Chief, Fire Department
Title
SUBJECT: Public Hearing - Merced Fire Department Emergency Medical Services Fee Schedule
REPORT IN BRIEF
Public Hearing to hear comments and adopt a resolution for the Merced Fire Department’s Emergency Medical Services Fee Schedule.
RECOMMENDATION
City Council - Adopt Resolution 2023-85, A Resolution of the City Council of the City of Merced, California, Adopting the Fire Department’s Master Fee Schedule - Emergency Medical Services and to Adjust Existing Fees for Inflation.
Body
ALTERNATIVES
1. Approve as recommended; or,
2. Approve, subject to other than recommended by staff; or,
3. Refer to staff for reconsideration of specific items; or,
4. Continue item to a Future Council meeting; or,
5. Deny the request.
AUTHORITY
Charter of the City of Merced, Section 412. Adoption of ordinances and resolutions.
California Government Code Sections 66014, 66016
California Health and Safety Code Section 19132-19132.3
CITY COUNCIL PRIORITIES
Public Safety, as provided for in the 2023/24 Adopted Budget.
DISCUSSION
History
The California Constitution grants cities the authority to establish fees to recover the cost of providing services. Previous City Council’s (1998) direction was to ensure that existing fees were calibrated to the cost of providing services. Since that time, the Fire Department’s Master fees have been periodically adjusted to reflect the cost of doing business.
On September 6, 2022, City Council approved the First Responder Fee Feasibility Study written by the third-party consultant, AP Triton; provided general support for MFD to return with a proposed resolution for the first responder fee; and to provide direction to establish a policy to defer billing all Medi-Cal and Medicare recipients and Private Party Merced City residents and provide direction to establish a Compassion Waiver Policy.
Following council direction, an Emergency Medical Services Fee Schedule for the Fire Department was developed and presented to Council for their consideration on the August 7, 2023, agenda. The Master Fee Schedule contained updates to fire prevention fees and EMS fees. After considerable discussion, Council decided to move forward with the update to the fire prevention fees and to separate the EMS fees for consideration at a future Council Meeting. Additionally, City Attorney Doyle advised that creating a separate fee schedule for EMS fees would be wise as they are different than Fire Prevention fees.
At the August 7, 2023, Council Meeting there was much discussion regarding the First Responder Fee. The fee, which currently exists within Merced County per Merced County EMS Agency regulation, is the responsibility of the ambulance contractor. Of the 11 fees discussed, the 9 transport fees were not discussed at length. A question was asked regarding the fees and Mayor Serrato stated to keep the transport fees the same as much work had been put forth in the development of said fees. It was asked that MFD return with the following:
• Prohibition of balance billing
o AB716 prohibits ambulance providers from sending a patient any bill beyond the in-network cost-sharing amount
o Federal No Surprise Act, a federal law which took effect at the beginning of 2022 protects patients from balance billing and surprise billing
• Adjustment of the Compassion Waiver Policy to reflect 3 times the Federal Poverty scale
o Table adjusted within DRAFT Compassion Waiver Policy
• Elimination of requirement for pay stubs and 10-40 form in Compassion Waiver Policy
o Adjusted within DRAFT Compassion Waiver Policy
• Customer service for those receiving a bill
o Contact information and hours shall be listed with the bill
o Will be established once a billing contractor is established
Problem Statement - EMS
Merced County EMS Agency (MCEMSA) administers a countywide contract for Advanced Life Support (ALS) transport services within Merced County. SEMSA/RIGGS is the awarded provider for MCEMSA as of the most recent award in 2020. The length of the current contract is for no more than five (5) years. MCEMSA monitors compliance standards set forth in the Request for Proposal and agreed upon within the contract. The contractor has been consistently, and significantly, out of compliance with their response times. As of the August 2023, MCEMSA Emergency Medical Care Committee meeting, SEMSA/RIGGS was noticed publicly that their organization had been in Material Breach of Contract more than 27-months. Additionally, MCEMSA publicly noticed SEMSA/RIGGS that their organization would not be automatically extended in their contract. Due to these many notable concerns, MFD is poised to support the EMS system by adding ALS personnel to the first response of the EMS system and adding transport capable apparatus to the MCEMSA’s rolling stock.
The City of Merced is one of six cities within Merced County which are in “High Call Density.” The High-Call Density response requirement is to have an ALS ambulance on scene within 10:59 seconds 90% of the time. This means that the ALS services have nearly 11 minutes to arrive and provide a recognized link within the American Heart Association’s “Chain of Survival.” In February the compliance for High-Call Density for the most acute EMS calls was 63.6%. That is 36.4% of the calls for the most acute medical requests receive an ambulance on scene more than 11 minutes with the advanced providers for the community. MFD has had multiple wait times in excess of 60 minutes and have even had wait times of greater than 120 minutes. This is an unacceptable reality within our community.
Another unacceptable reality is that for lower acuity calls the ambulance contractor is permitted to not send an ambulance per the contract. The contractor may “pend” a request for service until there is sufficient staff to respond. Wait times for a “pending” ambulance request may be up to 180 to 240 minutes.
The MFD proposes to offer transport services with basic life support (BLS) and advanced life support (ALS) ambulances. When available, the ambulance will respond to the previously mentioned low acuity requests as a first responder to evaluate patients. MCEMSA may authorizes ALS ambulances to operate within the MCEMSA system due to the need within the community.
MFD is at the ready to provide transportation of the ill and injured once approved by MCEMSA. In the meantime, an ambulance transport system needs to be developed. The establishment of a fee structure within the Master Fee Schedule is necessary for recovery of costs.
Outreach
The MFD has been active in gathering data to share with the community regarding the need for increased fire service. The safety of the community is at the core of every message.
In April 2023, the MFD established a Strategic Plan Committee (SPC) with over 40 members. Half of the team is made up of MFD firefighters and the remaining half is represented by members of the community. Community groups (NAACP, Boosters, Lao Family, etc.), educators (MUHSD, MCSD, MC, UC Merced), public safety (CHP, Fresno Fire, MPD, UC PD), real estate (realtors, insurance, etc.), medical community, and public partners (Merced County) are all represented within the group. A total of 7 meetings are planned and all have been completed. One meeting was specifically held on this subject, and the findings of those meetings are relayed within this item.
The SPC was provided factual data regarding the service gaps within our community for EMS delivery. The SPC developed objectives and strategies to be presented for both EMS delivery and Fire Prevention. Below are the Objectives and Strategies as represented by our community group which pertain to the Emergency Medical Services Fee Schedule:
EMS Objective 1. Explore expanded emergency medical services in the community which include injury/illness prevention.
Strategy 1. Development of a fee schedule
EMS Objective 2. Improve the quality of EMS care in the City of Merced and support the services within the County of Merced.
Strategy 2. Expand emergency medical services in the community to include ALS first responders and ALS and BLS ambulance transport.
Strategy 3. Establish an MOU with Mercy Merced Medical Center to ensure all Critical Care Transport patients are aided in transportation to a higher level of care when resources are not available or able to respond.
The proposed EMS Transport fees as set forth are within the rates set for MCEMSA approved fees (4 years ago) and represent a 25% savings to what current ambulance fees represent in the community. The current county provider established these fees in 2019 within the application to MCEMSA to operate as the ALS provider. These fees have been adjusted at least annually. The local ambulance fee schedule is in alignment with the private industry. As for the public sector, the fees which MFD is proposing are in alignment with other California Fire Departments.
Financial impacts for EMS delivery are very apparent within the community. A draft Compassion Fee Waiver Policy is attached within the agenda packet. The draft policy is guided by the United States Health and Human Services poverty guidelines and per council direction at the August 7, 2023, council meeting the table is adjusted to only reflect 3-times the poverty scale. It was recommended to return to council for direction on a Compassion Fee Waiver policy.
Outreach has been accomplished in the form of radio spots, utility bill inserts, advertisements in the Merced County Times and Merced Sun-Star, face to face meetings; phone calls, presentations to various community groups; and Town Hall meetings. Over 250 people have had direct contact, in intimate and comfortable settings with the Fire Chief. Individual meetings have been held in churches, community centers, and coffee shops in all districts.
The Town Hall meetings have also been quite well attended and have been in multiple districts within the City of Merced. On October 10, 12, and 18 the Merced Fire Department hosted the Town Halls at Merced College, Sam Café, and Merced City Hall respectively. Interpreters were present, while not utilized, and handout materials in both English and Spanish were dispersed. These opportunities have allowed the Fire Chief to personally hear concerned citizen’s viewpoints and to provide thoughtful feedback. All presentations have been met with good questions and the takeaway for the groups has been that the fire department is being “reasonable.” The consensus of the group was that some action shall be taken. Those who attended had common questions regarding the legal responsibility for the administration of the contract, how could the contract not be enforced, and what the MFD plan would be.
Staff Recommendations
Consistent with Council’s direction to recover fees for the provision of services, EMS service fees aid in recovering ongoing costs associated with the provision of Basic Life Support, therefore staff recommends adopting the proposed First Responder Fees to recover the cost of patient care provided by the first responders. Since pre-hospital care is a critical component of the healthcare system most medical insurances will reimburse this cost. In essence, the EMS program will be a fee supported program consistent with Council’s direction.
• Establish by resolution CPI adjustments annually on July 1st for all fees within the Merced Fire Department Emergency Medical Services Fee Schedule.
• Approve EMS transport fees for the following:
o BLS Transport
§ Non-emergent Interfacility Transfer (BLS-IFT)
§ Emergency (BLS)
o ALS Transport
§ Non-emergent Interfacility Transfer (ALS-IFT)
§ Emergency (ALS1)
§ Critical Emergency (ALS2)
o Critical Care Transport (CCT)
o Mileage
o Night Calls
o Oxygen
• Approve EMS Non-Transport fees for the following:
o First Responder Fee
o Treat/No-Transport
• Direction to return to council for adoption of Compassion Fee Waiver Policy
IMPACT ON CITY RESOURCES
Approval of the proposed update to the Fire Department’s Emergency Medical Services Fee Schedule will potentially generate additional annual revenue to the General Fund. After 12-months, staff will use the prior year as a benchmark in assessing the increased revenues.
The establishment of EMS transport fees do not create an impact on City Resources. Prior to ambulance transport program inception, Merced Fire Department will return to council after a Study Session regarding the proposed future of ambulance transport. If city council both provides direction on an EMS Fee Schedule and direction regarding staffing of an ambulance, a third-party biller will be contracted to manage the billing of EMS incidents. The billing contractor will coordinate the Intergovernmental Transfer of Public Provider Ground Emergency Medical Transport act funding. Personnel to staff the ambulances will be single function personnel and will need to be established as new labor personnel within the fire department.
ATTACHMENTS
1. Merced Fire Responder Feasibility Study
2. Resolution 2023-85
3. Draft - Compassion Policy