County Experiments With Privatizing Ambulance Service

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For the first time, private paramedics were deployed last week in Orange County to transfer patients between health facilities, a move that instantly generated ideological controversy and questions about quality.

County Health Care Agency officials designated a lone ambulance company to perform 100 inter-facility transfers beginning March 18 for a “study” to examine “the feasibility, safety and effectiveness” of having paramedics move patients previously cared for by critical-care nurses.

The new transfer method is part of an effort to ensure hospital beds are available for rescued patients by reducing overcrowding in emergency rooms.

But the agency’s selection of Lynch Ambulance Co. — an Anaheim firm that has long championed the idea of using private paramedics instead of fire department personnel — immediately drew sharp criticism.

The Orange County Professional Firefighters Association, the union that represents firefighters for the Orange County Fire Authority (OCFA) in 23 jurisdictions, filed a letter that day with the county demanding the new paramedic service be halted. The letter argued its creation violated county and state policies and law.

County officials dispute that assertion, and others say that using paramedics in interfacility transfers is a widely accepted practice.

In a separate letter addressed March 18 to Shawn Nelson, chairman of the Orange County Board of Supervisors, union President Dave Rose wrote that the “politically driven pilot program that has conflict of interest written all over it” will “seriously erode emergency medical service” for citizens. County officials rejected this criticism too.

Driven by ‘Ideology’

The OCFA firefighters see this minimal use of paramedics as the first step toward introducing private paramedics for potentially wider emergency use in the future, said Joe Kerr, the union’s spokesman. The program is driven by “ideology,” he said, and was implemented in “a cloak and dagger” manner.

The 15-firm Ambulance Association of Orange County also opposes the paramedic transfer concept, with its current president, Bill T. Weston, saying the move gives one firm an unfair competitive advantage for future service.

Weston, who is operations director for Care Ambulance Service of Fullerton, OCFA’s primary ambulance provider, added that the study “doesn’t make any sense” as less trained personnel will be caring for patients.

But agency officials offer a more benign description of the program, which was planned for at least a year and drew little interest until implemented.

Dr. Samuel J. Stratton, the agency’s medical director for emergency and disaster services, said that he had to “recruit” Lynch because no ambulance company volunteered for the study.

“We didn’t get any takers,” said Stratton, saying his agency put out notices and sought comments and providers for the study. Stratton said he then approached officials at Lynch Ambulance and those at Doctors Ambulance Service of Laguna Hills; the only two companies that met agency qualifications.

“Doctors Ambulance felt due to the politics, it was best to sit back and see how the pilot works,” Stratton said.

Pilot ‘Makes Perfect Sense’

Lynch Ambulance is the county’s largest interfacility transporter of patients with critical-care nurses, officials say.

Walter J. Lynch, the firm’s chief executive, said it “makes perfect sense” for his firm to conduct “a pilot designed to make sure policy makers receive accurate data to make an informed decision about what is best for patients.”

The number of patients requiring the advanced life support provided by critical-care nurses is relatively low, from 4 to 6 percent of all transports, some ambulance officials estimate.

The Hospital Association of Southern California issued a statement that Orange County facilities will continue to send patients with “medical staff” as determined by physicians. It had no comment “on the potential easing of requirements” for interfacility transports.

Paramedics are used widely for interfacility transports elsewhere in California, Lynch noted, calling it “an established standard of care.”

For decades, Orange County has had no private paramedics, with public agencies seen as providing the highest level of care with maximum accountability.

For nonemergency cases, ambulances staffed by emergency medical technicians — less trained than paramedics or nurses — transport certain patients between medical facilities.

In 911 rescue cases, paramedics from fire agencies respond to the scene and then use ambulances for the rapid runs to the most appropriate and nearest general, acute-care hospital. The pilot study will have no involvement with 911 rescues, agency officials said, adding that paramedics involved in interfacility transfers are prohibited from participating.

For more than a year, Stratton has expressed concerns about overcrowded emergency rooms being unable to admit patients brought by paramedics because no beds were available, either in the emergency bays or in intensive-care units. At times, emergency crews cared for patients until they could be admitted, officials say.

It can take up to three hours to procure an ambulance with registered nurse to transfer a patient, Stratton said. By offering a paramedic to care for the least serious patients, Stratton hopes to reduce that transfer-time response to within the 30 minutes required in the study.

On March 14, Stratton sent a memo to various emergency system leaders, notifying them of the interfacility paramedic program scheduled to start on March 18.

But the launch surprised a number of fire department and rescue personnel who believed program was still in the analysis phase. By March 19, some emergency agency officials didn’t know whether the program had actually begun.

Fire Chiefs Have Concerns

Among those who didn’t know was Wolfgang Knabe, who is fire chief for the departments in Fullerton and Brea, part of the North Orange County region where the paramedic study is being conducted.

Knabe noted that fire chiefs in general weren’t supportive of the idea when it was discussed in December at the county’s advisory Emergency Medical Care Committee. Knabe was appointed as the Orange County Fire Chiefs Association representative on the committee.

“It took us aback. We thought the proposal had been tabled, that there would be a lot more discussion before it was approved,” he said.

On March 21 at a fire chiefs’ regular meeting, Stratton briefed them on the paramedic study.

Afterwards, Knabe said, the fire chiefs opted “to see how the pilot program works” before making further comment. But he added that concerns remain about using paramedics because of what was termed “a denigration of service skills.”

Countywide, the emergency services system remains divided by concerns and distrust about a potential move toward privatization. Some authorities have said privately that they fear that some politicians looking to save money don’t understand the consequences for saving lives.

For instance, Stratton’s study has not been endorsed by the county fire authority. Its fire chief, Keith Richter, declined to be interviewed. His spokesman, Kris Concepcion, said the agency “was not taking a position” on paramedic interfacility transport at this time.

But the firefighter’s union quickly issued a letter charging conflict of interest within the paramedic study.

Lynch Ambulance’s business development director, Patrick J. Powers, was a county regulator of paramedics. He now sits on the emergency committee, which under state guidelines advises on various services.

Orange County Supervisor John Moorlach, known statewide as a strong advocate of privatization, appointed Powers to the committee.

Despite the criticism, Stratton said county executives have given him full support for the pilot program. At least eight patients were transported by paramedics between facilities in the first three days, Stratton said.

The program “is going better than expected,” he said. “We are optimistic this pilot will be a huge success for Orange County, its citizens and our patients.”

Rex Dalton is a San Diego-based journalist who has worked for the San Diego Union-Tribune and the journal Nature. You can reach him directly at rexdalton@aol.com.

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