By Conrad Swanson

The Gazette

COLORADO SPRINGS, Colo. — American Medical Response's ambulances have consistently been late in responding to emergency calls, representing an "imminent threat" to the public's safety, according to complaints.

Last year, the company paid more than $300,000 in penalties to Colorado Springs and El Paso County for more than 4,200 instances in which ambulance crews failed to meet their required response times under separate contracts with the two governments, a Gazette analysis of records has found. In February 2017, one crew surpassed the city's 12-minute limit by more than 43 minutes.

On 19 occasions since 2015, AMR failed to dispatch a crew within 10 minutes of receiving a call for service. Those instances - which include an overdose or poisoning, violent injuries, an allergic reaction and heart problems - were attributed to lapses in communication between crews and dispatchers, city compliance reports show.

AMR Regional Director Scott Lenn said the issues have been addressed and the company is meeting its contractual agreements.

"It's been nothing but praise for the last six plus months," he told The Gazette recently.

Rethinking agreements

AMR's response times, among other issues, have prompted Colorado Springs to consider a switch in providers. The city and county contract with AMR to provide ambulance services, but neither pays anything to AMR, which recoups its costs and makes a profit by charging patients and insurance companies for its services.

The city recently started negotiating with Priority Ambulance, of Knoxville, Tenn., which might replace AMR as the city's ambulance provider next year. Priority's bid promises more economical services. El Paso County is also changing its contract with the company in an effort to make the agreement more attractive to companies when it goes out to bid in 2019.

County commissioners voted unanimously on Thursday to remove rate controls from the company's agreement with the county's Emergency Services Authority, which oversees ambulance services in Manitou Springs, Fountain and unincorporated areas.

The price limits, in place since the beginning of the contract in 2014, kept the contractor from charging patients and insurers enough to cover its costs, said Carl Tatum, board chairman for the county's ESA.

"There's a great possibility that a year from now or a year and a half from now, there may not be anybody that bids on this contract," said Tatum, who's also the fire chief for Hanover Fire Protection District. "What we're trying to do as a board right now is just to figure out how do we make the best system that we can with the resources available, and basically this is our last-ditch effort."

Tatum said the decision was unrelated to the city's decision to pursue a new contractor.

AMR has no immediate plans to boost rates because of the change in the county's contract, Lenn said.

The company's shortcomings have resulted in complaints from the Colorado Springs Fire Department, which also provides emergency medical care. Those complaints, obtained by The Gazette, detail instances where AMR's ambulances arrived without stretchers and the company's dispatchers requested aid from firefighters reportedly to prevent "overtime costs or inconvenience to their crews."

A complaint from August 2017, shows that in two separate incidents AMR allowed employees lacking the proper certifications to respond to calls. Starting that September, the city required written verification of certifications for all AMR employees.

Many other complaints refer to the company's failures to respond to calls, which the Fire Department considers "a substantial and imminent threat to the public health and safety of the citizens of Colorado Springs."

Doug Wolfberg, a Pennsylvania-based EMS attorney and consultant, called a failure to respond a "significant issue" and said governments should hold their contractors accountable for such lapses.

"If it's isolated or sporadic, I won't say it's forgivable, it may be explainable," he said. "But if it's consistent or a pattern, then I think an investigation of contractor practices is warranted."

Since the split

Tatum and other ESA officials attribute some of AMR's troubles to the city's 2013 decision to pull out of its joint contract with the county.

At the time, then-Mayor Steve Bach said the move would allow the city to renegotiate a new agreement and it would save money by requiring AMR to reimburse the government for time fire crews spend at scenes before an ambulance arrives. Bach said the county's ESA was invited to join in the move, but it never did.

Compliance reports show that AMR's response times in the county have crept upward since the split. Each month last year, average response times were measured below what they were before 2014 in two or more of the county's seven response zones. In each of those zones, AMR has a different amount of time to respond - ranging from 12 minutes in suburban areas to 45 minutes in rural - before an ambulance is considered late.

Bill Normile, a citizen representative on the ESA board, said in a November letter to Mayor John Suthers that the city's reimbursement requirement has added to AMR's load, resulting in fewer ambulances on the streets, a higher turnover rate for emergency medical technicians and paramedics and an increased reliance on mutual aid partners such as local fire protection districts.

In the letter, also sent to City Council President Richard Skorman, Normile asked the city to reconsider working with the county again to provide ambulance service to the region. On Wednesday, he told The Gazette that his board is collaborating with Ted Collas, the city's fire chief, to improve response times for both entities.

In addition to the $300,000 in penalties, under its new contract, AMR has reimbursed the city $1.17 million each year for fire crews' time waiting for an ambulance. That's been upped to $1.4 million in the city's request for proposals in January.

"That money has gotta come from somewhere," said Tatum. "When your employee costs, your fuel costs and the maintenance, your equipment costs are continuing to rise, something's got to give, and sometimes it's just man-hours. They can't put enough cars on the street due to the economics."

Lenn said AMR had to make some changes to cover that reimbursement requirement, including leaving some positions open - which he acknowledged has added to response times.

He said staffing levels have increased slightly since 2014 but couldn't say how much. The number of ambulances serving the county and city, however, has remained at 38, Lenn said.

Shifts to cover those added expenses have forced the company to become more efficient, said Operations Manager Shawn Howe and Administrative Supervisor Jess Baker.

Howe said that the staff's workload in serving the area has increased by about 25 percent.

On top of the already-stretched crews, Howe said AMR only recoups 30.4 percent of its costs. This is largely due to the mix of parties responsible for making payments, which include insurance companies, Medicaid, Medicare and the patients.

Despite any disagreements or shortcomings with the current contract, Lenn questioned why the city might switch providers.

"I don't know why you would change something when it's not broke," he said.

Cutting price controls

Local officials and industry experts said they didn't see a major risk in removing the price controls from the county's contract.

"It's really about covering the costs," said county Commissioner Stan VanderWerf, who's on the ESA board. "I'm just not a fan of government rate controls. I'm much more interested in the market doing its job."

Even a short ride in an ambulance can be expensive. Under the limits that were eliminated from the county's contract, AMR charged a base rate of $640 or $860, depending on the type of call, plus about $20 per mile and additional costs for any medical equipment or drugs used to care for the patient.

Statewide, the base pricing for ambulance ground transport averages about $1,000 per trip. Specialty care costs may add a few thousand dollars more to the bill, according to data self-reported by ambulance companies to the Colorado Department of Public Health and Environment.

The state does not appear to offer protections for patients facing ambulance bills. Colorado statute limits how much a patient may be charged for out-of-network care, but those laws don't apply to ambulance services.

Wolfberg, EMS consultant and attorney, said such rate controls "give the illusion of consumer protection," but don't make a difference in the bill a patient receives.

"Very few ambulance bills are paid by the individuals, by the patients," Wolfberg said. "The self-pay part of a payer mix is probably less than 5 percent, so when you look at the number of patients who actually pay out of their pocket, it's small."

According to its website, AMR offers a payment plan, called the Compassionate Care Program, for "patients who are experiencing financial hardship with out-of-pocket ambulance transportation expenses."

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