by Rufus Jeffris
TThe faded, fire engine-red sign in the front yard of a Menlo Park home on Laurel Avenue could easily be confused with those annoying placards that always sprout from lawns during elections. But this sign has nothing to do with next month's election. It doesn't declare a candidate's name or shout a breezy political slogan. In fact, its inscription delivers a more ominous warning: "Because minutes count."
For many people who read the sign posted in the Willows neighborhood yard and in others around the city, the brief message may be all they know about a bid by the Menlo Park Fire Protection District to launch a paramedic and ambulance service it contends will save money and lives.
The signs, however, offer little insight into the aggressive campaign the district and its firefighters have waged since 1989 to expand dramatically their role in bringing emergency medical care to the 83,000 residents they serve in Menlo Park, East Palo Alto, Atherton and parts of San Mateo County.
Beyond their cryptic warning, the signs don't explain why the district's elected leaders think they can do a better job than BayStar Medical Services, the private company that holds an exclusive contract to deliver San Mateo County's emergency services until Jan. 1, 1996. And why they think they can charge an average of about 20 percent less than BayStar to do it.
Nowhere do the signs say how the supposedly cash-strapped district, which last year laid off 12 employees and pleaded with voters to approve a five-year, $9.5 million parcel tax, expects to come up with the at least $1.3 million it's expected to cost to get the venture rolling.
The signs don't explain why it's taken the district five years to present publicly a plan telling taxpayers what the costs might be.
Neither do they shed any light on how much the district has spent so far on the effort. Nor do they say what has inspired more than two dozen firefighters to give up what could amount to hundreds of thousands of dollars in potential overtime pay to train as paramedics.
And the signs don't mention the pitched battle Fire Chief Rick Tye has waged with state legislators and the county's top health officials and their ambulance contractor over who holds the authority to decide whether the district can go ahead with its plans.
It's a battle that preceded Tye's arrival at the district in 1992. And it's one that could wind up in the courts, the same place similar disputes have landed in San Bernardino, Santa Barbara, Petaluma and Sacramento over the past several years.
So what's it all about? Can the district do all that it says? That is, can it: provide faster, less expensive paramedic and ambulance service than is currently available; ensure that the care is of at least the same quality; and keep its promise that taxpayers won't be stuck with a big, fat bill?
More fundamentally, should it be doing those things, and why? Is there a good reason why an agency created in 1917 solely to fight fires should now start loading life-saving drugs and medical equipment alongside its hoses and axes on brand-new $150,000 fire engines that double as ambulances?
Tye and other fire officials think so. That's why the district's directors last week gave Tye the go-ahead to embark on a program to put paramedics on fire engines by September and told him to continue negotiating with the county for an agreement that would allow it to launch its own ambulance service.
These efforts, they said, reflect the district's response to the community's changing demands for emergency services. No longer is the district called upon simply to douse fires. According to its own numbers, an estimated 75 percent of the district's 911 calls come from people seeking some form of emergency medical treatment, for everything from broken bones to heart attacks.
"This is a critical turning point for the fire protection district and the way we're going to deliver service to our customers," Tye said. "The first question we wanted to know was, what business are we in? I think we all agree it's a lot different than when we started 77 years ago."
In the context of the changing demand and the district's broad mission of saving lives and protecting property, fire officials questioned whether the district was properly equipped and adequately trained to provide the best emergency medical care to the people it serves.
"They deserve the highest level of service available," Tye said.
Which brings us back to the admonition printed on those yard signs. Because in the context of saving lives, the district started from the premise that prompt emergency medical care can make a difference.
The district's firefighters almost always arrive at an emergency sooner than BayStar's ambulances and paramedics. Not even BayStar officials argue this point. In a study on arrival times that the county conducted in 1991, the district beat BayStar to the scene by an average of two minutes.
That's exactly how the district has framed its campaign for paramedic and ambulance service since 1989, when former Fire Chief Jack Bennett first introduced the idea. The district's ability to respond quickly isn't surprising. Firefighters staff six stations within the district's borders. BayStar covers the same area with at most two ambulances.
"We are there earlier," said A. Erwin "Erv" Ericksen, chairman of the district's board of directors. "We think that's important."
Although county health and BayStar officials agree the district's presence offers patients a rapid first response, they don't necessarily agree that it's a convincing argument for putting firefighters through expensive paramedic training.
That's because there's little more firefighters can do for patients than they already do during those few minutes before BayStar arrives, regardless of whether they're trained as paramedics, according to Barbara Pletz, the county's emergency medical administrator.
As it works now, firefighters trained as emergency medical technicians deliver what's known as basic life support. In treating a heart attack victim, they can perform cardiopulmonary resuscitation (CPR), pump oxygen to a patient and shock patients with a defibrillator, an electrical device that jolts the heart back to life.
With paramedic training, the district argues, firefighters could also begin giving patients potentially life-saving drugs. And they could do it more quickly than BayStar.
Pletz disagreed. She pointed to a county survey that showed paramedics administer medication in only about 13 percent of emergency medical calls and usually not until 15 minutes after they've begun treating a patient.
"I think Rick Tye or anybody else would be hard-pressed to show that anything would change in the first one to two minutes by putting paramedics on fire engines," said Christian Callsen, director of education and training for BayStar.
The district contends, however, that the gap in arrival time is not the only place where precious minutes are lost during emergency treatment. According to Rex Ianson, a director on the Menlo Park Firefighters Association board, delays in care of several minutes also can occur when firefighters transfer control of treatment to arriving BayStar paramedics.
Unfamiliar with the patient's condition and the treatment already given by firefighters, Ianson said BayStar paramedics generally "end up going through the same basic things . . . They need to know for themselves" what's happened up until their arrival.
Although county health officials have acknowledged that these delays occur, Pletz is quick to add that there's no hard evidence to suggest that patient care suffers. And, she said, similar delays could as easily result because of disagreements between district and BayStar paramedics over what medical treatment to give.
The only thing that appears certain from this discussion is that the two sides could argue until they're blue in the face over whether firefighters should be permitted to work as paramedics.
Dr. Eric Weiss agreed that there's no easy answer to the question. Weiss is an assistant professor of emergency medicine at Stanford University and medical director of the university's Paramedic Training School. In a lot of cases, he said, having firefighters with paramedic skills may not make a significant difference in the level of care patients get.
However, "on a few cases it may save a life," Weiss said. And in those cases, particularly heart attacks, he added, "yes, I would say it definitely will make a difference."
Eliminating the confusion that could potentially arise from having both firefighters and BayStar respond to a medical call is a big reason the district wants sole control over its own emergency services. But there's more at stake for the district in its paramedic push than shaving minutes from response times. That's because the district wants to transport patients in its own ambulances. And for good reason. The way the system works now, the district can't charge patients only for paramedic care. It can only recover those costs by billing them to patients as part of an ambulance ride to the hospital.
Nonetheless, fire directors last week directed Tye to move ahead with plans to start paramedic service in September that is estimated to cost up to $100,000 annually to operate. Without ambulances, however, that money comes straight out of the district's pocket.
"It's a short-term cost the district can carry," Tye said.
Which raises several other important questions that those red yard signs don't directly address. Specifically, what's all this going to cost the taxpayers whose money runs the district and the patients who would be paying to ride in its ambulances? Is it affordable for either?
Under the chief's proposal, the district would initially pay $1.3 million to replace BayStar within its borders.
The greatest expense would come from spending $670,000 to buy four new fire engines that double as ambulances. Known in fire industry lingo as rescue ambulance mini-pumpers, or RAMPs, these vehicles can carry up to three patients, five firefighters and their medical gear and enough water and hose to put out small fires.
Equipping its paramedics with medical supplies is expected to cost the district $240,000 each year.
Another $205,000 annually would cover increased insurance costs of $15,000, administrative costs of $85,000, training costs of $50,000, maintenance and fuel in the amount of $35,000 and medical consulting fees of $20,000.
The district's proposal also sets aside at least $200,000 annually in overtime and incentive pay for paramedics. Tye said the money helps repay the more than two dozen firefighters for some of the hundreds of thousands of dollars in total overtime pay he said they've voluntarily given up to attend paramedic training.
Although he expects the district to lose money from its paramedic service during the first year, Tye said the decision to go forward with it and the ambulance program represents the district's best chance to improve service to residents and increase efficiency in the department.
"We're not talking about hiring new people; we're talking about maximizing the productivity of our current personnel," Tye said.
However, the figures prompted one woman at last week's board meeting to question how the district, after laying off 12 employees and cutting $1 million from its budget last year, now can afford to absorb the $100,000 in paramedic costs and propose spending another $1.3 million to get the ambulances running.
Indeed, the proposal comes less than a year after the district told the community that its financial survival and possibly the fate of three stations hinged on voter approval of a five-year, $9.5 million parcel tax.
Better-than-expected budget news from the state last year turned around the district's fortunes, Tye explained, averting the need to impose the tax. The fire district board still can impose the levy without going back to the voters, but it has promised not to use it to pay for its paramedic and ambulance service.
Besides, Tye said, the district can get the service going, charge patients an average of about 20 percent less, or $626 per ride, than the $794 BayStar currently charges for ambulance transport and still clear an annual profit of about $124,000. And under a complex scheme Tye is exploring in which the district would bill patients through a non-profit organization it set up earlier this year, the money would be shielded from state budget cuts.
In addition, he says the district will save up to $125,000 by replacing fire engines with the less expensive RAMPs.
"The anticipation is, yes, there will be a financial gain or otherwise we wouldn't be doing this," Director Robert Boeddiker said.
Tye's figures come from a feasibility study he compiled last month with the help of Allied Billing, a private medical billing company in Berkeley.
"That's a wonderful promise, but there's absolutely no data to support that," said BayStar's Callsen.
The reason, Callsen believes, is that the district has underestimated the cost of starting and running ambulance service and also seriously overestimated the amount of money it expects to collect from patients in an area of the county with historically low collection rates.
"It is a massive undertaking, it's not any small task to get this up and running," said Pletz, the county's emergency services administrator. "Unless you do a large enough area, it's not going to be cost-effective for the district."
As a private company, BayStar doesn't get a cent in public subsidies from the county. Its contract with the county does give it a leg up in the lucrative non-emergency ambulance transport market. But BayStar fends for itself in recouping the cost of its emergency business.
On average, Callsen said, BayStar collects no more than 55 percent of what it charges. But that figure is spread out over the entire county. In the region the fire district covers, he said, the collection rate is nearer to 26 percent. That's because the majority of emergency calls within the district come from areas where residents can't afford to pay either all or part of the full charge, Callsen said.
District officials don't disagree that those areas generate the bulk of their calls, but Tye maintained that the district will get at least 35 percent. Counters Callsen, "there is no way they're going to collect" that much.
"We're still working on this thing," said Director Peg Gunn. "But the thing is we know we can do this cheaper."
That may be true. But the district faces fierce opposition to its plans from San Mateo County and probably more than one lawsuit if it attempts to push ahead with ambulance service before BayStar's contract expires at the beginning of 1996. While county officials have said they would consider the district's proposal to put paramedics on fire engines, they've flatly rejected its bid to run ambulances.
The county worries that allowing the district to operate its own ambulances would seriously disrupt BayStar's service, push up its costs in other parts of the county and possibly its response times, Pletz said. The county thinks the best approach to ambulance service is to have a single provider.
"When we start chopping it up into small pieces they become more expensive and less efficient," Pletz said.
The two sides have clashed repeatedly over whether the district or the county holds the authority to decide who will provide ambulance transport services.
County officials says state law gives them the power. The district has forcefully maintained that it can act on its own. In the past several months, Tye has spent time in Sacramento lobbying against legislation that would clearly spell out the county's authority to approve emergency services. The Menlo Park Firefighters Association chartered a bus to join him last month at a Capitol hearing on the bill, AB 3156.
Similar battles are currently playing out between a handful of fire departments and counties statewide. In Sacramento, Santa Barbara and Sonoma counties, the disputes have ended up in court. And in San Bernardino County, the Colton Fire Department remains locked in a legal battle with the county as the two sides attempt to sort out whether a judge's recent ruling gives one or the other power to decide who will control emergency services. Attorney's bills on the department's side have topped $60,000.
Obviously aware of the prospect of a legal challenge, the district's board last week sought to smooth its less than congenial relationship with the county by appointing directors Gunn and Ericksen to discuss Menlo's ambulance service plans with a committee of health officials and supervisors Ruben Barrales and Mike Nevin.
Tye has also expressed interest in a proposal the county Fire Chiefs Association is exploring in which fire departments together would approach the board of supervisors in 1996 with a plan to replace BayStar countywide. Pletz indicated that the county would welcome that kind of countywide approach. But it's unclear the association would be ready to advance its proposal at the time BayStar's contract expires.
"We have been saying from the start we want to work with other people, we want to work with other fire districts," Tye said. "Sure, we would participate in that plan."
Aside from the questions that officials from the county and BayStar have raised, there has been almost no public criticism of the district's plans.
That's not entirely unusual for the district, which traditionally enjoys broad community support and rarely comes under intense public scrutiny. Its monthly board meetings are sparsely attended. And at a time last June when voters in the rest of the state were saying no to an array of local tax increases, the district succeeded in convincing residents here to approve a $9.5 million parcel tax by an astounding 71 percent.
But the silence has caused both Pletz and Callsen to wonder whether the district and its firefighters have presented enough information about its plans or are counting on stirring emotional support with signs like those which appear around town.
"Are you willing to turn over your emergency medical service system to someone who promises they can do it but has never done it?" Callsen asked.
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