JACKSON — On paper, it takes an ambulance less than 10 minutes to reach most patients living in Hinds County. In reality, it could take a lot longer.
That’s because Hinds County’s contractual arrangement with its emergency medical services provider can make response times appear shorter than they are.
According to the agreement Hinds County struck with Colorado-based American Medical Response, the ambulance company must respond to most emergency calls within eight minutes.
However, the contract contains a number of exceptions such as high volume periods and inclement weather that do not count against the company’s response times, a Mississippi Today/WLBT analysis of statewide contracts shows.
In 2018, there were more than 32,000 emergency calls in Hinds County, the most populous in the state. A review of those calls showed an average trip time — starting from the time the ambulance is dispatched to when a hospital admits a patient allowing the ambulance to go back in service — of an hour and a half.
Last year, half of calls were exceptions, which includes delays caused by weather, construction, and what the contract defines as excess volume. In Hinds County, excess call volume — essentially, when the ambulance company’s fleet is maxed out — kicks in at eight or more active trips at one time. In 2018, one-third of all emergency runs, more than 10,000 trips, were exempt from AMR’s response time performance due to “unusual system overload.”
Rick Narad, a national emergency medical services researcher and professor at California State University at Chico, called the agreement unusual and akin to a get-out-of-jail-free card.
“You’ve got a combination of a very friendly contract and inadequate oversight,” because excluded response times are omitted from the contract’s accountability measures. “That scares me because it means that we don’t really know what the provider is doing. We’ve given them an exclusive (contract), but we’re not holding them accountable.”
Jim Pollard, a public affairs manager with the company’s Mississippi office, defends the Hinds County agreement as a good deal for taxpayers. Under the contract, Hinds County agrees to pay the company just 15 cents per Hinds County resident (roughly $36,000 per year) to provide critical emergency services.
In return, Hinds County agreed to allow certain exceptions as well as granting AMR exclusive rights to non-emergency calls such as taking nursing home patients to scheduled doctor visits; these calls provide the bulk of revenues for emergency medical service providers.
“That path is for government officials to select, through a competitive process, one and only contractor who transports all of the community’s emergency and non-emergency ambulance patients,” Pollard said in a written response. “If local government allows multiple companies to provide non-emergency transports, then the contractor for 911 transports will be financially crippled.”
Hinds County is a microcosm of the challenges facing the emergency medical services industry across the U.S. as well as communities grappling with myriad problems of shrinking government budgets and crumbling roads and bridges.
Nationwide, emergency systems provide $2.9 billion worth of uncompensated care yearly, according to a 2016 National EMS Advisory Council report that recommended increased federal reimbursement rates. The report points out that total loss includes charity care, under-reimbursement from Medicare and 911 calls that do not result in trips to the hospital.
Pollard explains that such exclusivity agreements as its Hinds County provision provides a degree of stability in an otherwise unpredictable business climate. For example, when patients lack health insurance, emergency medical service providers lose money. And even insured patients come with varying reimbursement rates.
In areas with high poverty rates and uninsured rates like Jackson, many ambulance trips can go uncompensated. Kyle Greer, Hinds County’s emergency services coordinator who authorizes AMR’s response times and excluded calls, says the long waits, high volume and uncompensated care costs are systemic across the country.
“It’s not just an ambulance issue. It’s not just a hospital issue. It’s the whole across-the-board gambit. … It’s a Catch-22 in so many different ways. The whole system is broken from start to finish but nobody can really go in and fix the entire system,” Greer said.
Hinds County is one of the few across the state that mandates response times in their ambulance contract. The county requires the company to meet 85 percent of its Jackson and Clinton emergency calls in eight minutes or less. AMR has to respond to outer-Hinds County calls in 18 minutes or less.
When someone calls 911, the call goes to a dispatcher run by a local police department or an answering service that sends an ambulance to the patient. Depending on where the ambulance is coming from and the size of the ambulance company’s fleet, the minutes can add up, especially in rural areas. In a perfect world, the paramedic gets to the patient quickly, takes them to the nearest hospital, hands off the paperwork and hits the road for next patient trip.
But there’s another complicating factor in calculating response times, according to paramedic reports, research and our analysis. Paramedics dub it wall time, which refers to the amount of time it takes to get a patient from the ambulance stretcher to a hospital bed. Wall time, emergency medical service providers say, has long plagued providers of all sizes. In smaller counties, it could mean hours without a dedicated ambulance provider.
Industry experts agree that ambulance response times will get longer before they get shorter. In Mississippi, increasing consolidation among ambulance providers, deteriorating infrastructure and the rate of rural hospital closures are increasing the length of calls.
In Hinds County, wall time eats up half of all emergency calls — an average of about 45 minutes every time a paramedic picks up and drops off a patient. Data show that wall times compound over the course of the day. Between 11 a.m. and 3 p.m. is when call volume peaks, creating ambulance log-jam at emergency departments that are unable to return to service.
Big companies with large fleets, like AMR who contracts with 19 Mississippi counties, can better absorb some of these losses or work with counties to carve out exceptions for them in their contracts. Smaller companies have to eat it, but many small operators fear that it could drive them out of business, weakening the public safety of ambulance providers and, possibly, cause corporations to raise their prices as competitors die off.
“Nobody knows it yet because we’re that duck paddling like hell under the water and staying afloat. But we’re actually in crisis and it’s going to hit critical mass. I don’t know what it’s going to look like but it’s not going to be healthy for people … If we ever take this veil down, people will realize that it’s really kind of scary,” said Tyler Blalock, who operates Rural Rapid Response in southwestern Franklin and Lawrence counties.
A question of oversight
Blalock, a former AMR paramedic who started his own company in 2012, echoes the California professor in calling for more accountability in his industry. But debate has long swirled over who exactly should provide the oversight.
In Mississippi and around the nation these life-and-death matters are determined by a largely unregulated patchwork of private EMS providers making deals with local counties, and emergency medical providers striking loose unregulated and unenforceable compacts amongst themselves. No state agency independently regulates response times, and a federal database maintained by the National Highway Traffic Safety Administration relies on emergency medical services providers to voluntarily provide response time data.
In short, emergency medical service providers, which emerged in response to an increasing number of car wrecks in the 1960s, are regulated and paid mostly as transportation companies that the U.S. Department of Transportation oversees rather than medical providers.
The Mississippi State Department of Health inspects and regulates the equipment on emergency medical vehicles, and licenses some 2,100 paramedics and emergency medical technicians across the state. Otherwise, accountability rests with individual counties in enforcing the terms of their contracts and acting in the best interest of their citizens.
In a longstanding dispute between emergency service providers and hospitals over the question of who is responsible for patient care at the emergency department, the state attorney general’s office recently advised the health department that under federal law, hospitals are responsible for patients when on hospital grounds.
Emergency services experts agree that more such clarity is needed. In the meantime, as pressures mount on ambulance service providers, so does the risk for patients.
“You better hope you’re not the third heart attack in the county that night or you’re gonna be waiting a very long time,” said Ryan Kelly, director of the state’s rural health task force.
“If you have something very serious, there’s two ambulances out on a call and you’re the third call, you better get in the car because you’re going to be waiting hours. And that’s a very scary thought that you may live or die depending on whether you were first in line.”
This is the first part in an occasional series about emergency medical services in Mississippi. In Part II, we look at the challenges facing small rural providers.
We requested 2018 emergency transports from Hinds County. Using the total length of time of each trip – from dispatch to going back in service – we subtracted the time spent at the hospital to get total “wall time” for each trip. We also calculated the average and the median time spent treating/transporting patients as well as wall time.
This same dataset included the total number of calls that were excluded from overall response times for each month. We used this data to average the number of calls across the year not used toward AMR’s performance metrics outlined in its Hinds County contract.
After sorting the transport data in chronological order, we used a formula to count how many trips were ongoing each time a new call was received.
This told us how many times a trip was the eighth (or higher) simultaneous trip, meaning that it was excluded from AMR’s performance metrics due to what the contract calls “unusual system overload.”
References to an average day, the busiest or least busy day are based on the number of trips per day in 2018.
We also requested total wall time for transfers from hospitals across the state from Mississippi State Department of Health, to calculate how many trips left their region to seek care in Jackson.