Fort Worth has been a part of the MedStar EMS system since 1986. But as the public utility continues to struggle with rising costs and declining reimbursements, council members are taking a closer look at alternative models.
Representatives from Fitch & Associates presented four potential EMS models to the city’s EMS committee Feb 20. The first would closely resemble the current public utility model, but the Fort Worth City Council would take on a greater governance role within MedStar. The second would create a fire-based model, where either civilians or sworn fire department personnel would handle EMS services. The third would establish a new, third service within city governance. The fourth would switch the EMS system to a private-contractor model.
Consultants provided high-level cost estimates for each model, which ranged from $3.2 million to $63 million. Each estimate assumes an 8-minute response time goal.
“We took the kind of the worst-case scenario approach (in cost estimates) because we want to make sure everyone’s going in eyes wide open,” assistant city manager Valerie Washington told the Fort Worth Report. “But there are definitely opportunities to weed out inefficiencies, duplicative efforts, all of that.”
The recommendations from Fitch & Associates come as part of a $182,500 contract to reimagine EMS services in Fort Worth. It’s the first time in more than a decade that the city has commissioned a comprehensive study of its EMS system.
Consultants are expected to give their final recommendations at a March 19 committee meeting, and council members will decide which model recommendation to move forward with. Regardless of what direction the council takes, Washington emphasized that the city is committed to working with other jurisdictions, area hospitals and MedStar employees.
“We know that people are nervous, but we want to try to calm that as much as we can, because we value them and their work as paramedics and EMTs,” she said. “And as we make any transition, they will be a part of that discussion.”
Option 1: MedStar remains, with City Council governance
The first alternative model suggested by the consultants would give Fort Worth City Council greater authority in MedStar’s governance structure.
Currently, MedStar’s board of directors is composed of four members chosen by the city of Fort Worth, one resident from the service area, two members of the emergency physician advisory board, and two members of the first responder advisory board. The MedStar CEO and medical director sit on the board in nonvoting roles. Board members provide overall system direction, including setting performance goals and standards.
Under the current interlocal agreement, Fort Worth could assign council members to fill its four positions on the board and continue to have Fort Worth Fire Chief Jim Davis serve as a representative of the first responder advisory board. That would give city leadership the majority of the votes on MedStar’s board and allow the Fort Worth City Council to take a more active role in governance immediately, according to the consultants.
Alternatively, the city could try pursuing an amendment to the current interlocal agreement and replace the existing MedStar board with the entirety of the Fort Worth City Council. Amending the interlocal agreement requires unanimous consent from the other member cities. Currently, there are 14 member cities across Tarrant County that get their EMS services solely from MedStar.
Under that approach, two different advisory boards would report to City Council members — the medical control board and the EMS advisory council. The Office of Medical Director, which currently works out of MedStar, would become fully independent.
Fort Worth City Council would provide public funding to MedStar to continue operations, effectively preserving status quo with the exception of the board changes. The city would employ an EMS system administrator to handle running the system day-to-day.
Steven Knight, a consultant with Fitch & Associates, said switching to a City Council form of governance is the cheapest option of the four. It has an estimated cost of $3.2 million.
Option 2: Fire-based EMS
Right now, all Fort Worth firefighters are trained EMTs. A smaller number are certified paramedics. Firefighter crews respond before, alongside or after MedStar during serious medical emergencies.
Under the second model proposed by Fitch & Associates, the fire department’s role would expand. Instead of working with MedStar, the fire department would replace the EMS provider and establish a fire-based EMS service for the city.
The fire-based EMS could be staffed by either civilians or sworn firefighters. Assuming that the city doesn’t receive any of MedStar’s assets (like cash, facilities and equipment), consultants estimated establishing a civilian fire-based EMS system would cost $50.5 million, while establishing a system with sworn firefighters would cost $63 million.
If the city does receive MedStar’s assets — which would require either the complete dissolution of the EMS provider or Fort Worth’s withdrawal due to the provider’s failure to provide adequate ambulance services — costs would decline. Assuming the city would receive the necessary capital assets from MedStar, civilian fire-based service would cost $10.5 million, and a service with sworn firefighters would cost $23 million.
Houston, Dallas, and San Antonio all use sworn firefighters in fire-based EMS systems. Chicago, Philadelphia and New York City use a civilian fire-based EMS system.
The union representing Fort Worth firefighters, IAFF 440, has previously pushed council members to consider a switch to fire-based EMS. In an earlier 2008 study, Fitch & Associates cautioned leaders against moving in that direction — but now, more than a decade later, Fitch has reconsidered, and council members have indicated all options are on the table.
Option 3: Third service model
In Austin, the Austin-Travis County EMS acts as a third public safety service alongside police and fire. Under the third model proposed by Fitch, Fort Worth would transition to a similar third service model.
This model would require the longest transition and implementation period of any of the recommendations. It also carries the second-highest cost behind a fire-based EMS system staffed by sworn firefighters.
To make the switch to an entirely new third service, Fort Worth would need to build new organizational structures and invest about $40 million in capital outlay, for a total of $55.3 million. That’s assuming the city doesn’t receive assets from MedStar; if Fort Worth does receive assets, the cost would drop to $15.3 million.
Alternatively, the city could have MedStar act as a third service, rather than retain its current role as a public utility. That switch would total $11.6 million for public funding and things like dispatch and legal costs.
Option 4: Private contractor
In Arlington, EMS providers are chosen through a competitive bidding process. American Medical Response was first selected as the city’s private contractor in 2008 and has since had its contract renewed several times.
Under the fourth option presented to council members, Fort Worth would follow the same competitive bidding process as Arlington. Under that model, Fort Worth would collect net revenues from emergency transports, and the contractor is paid an agreed-upon rate.
Knight said a benefit of this model is that it allows for greater accountability. The private contractor is contractually obligated and incentivized, he said, to meet desired deployment levels and response times. Theoretically, MedStar could continue to provide EMS services as a contractor, providing it wins the bid.
The estimated cost to move to a private contractor system is $9.4 million.
How we got here
MedStar’s call volume has increased by more than 6% over the past two years, but an accompanying increase in revenue hasn’t materialized. The EMS provider is spending more money responding to emergency calls than it is earning back, resulting in expenditures that have at times outpaced collections over the past five years.
As a result of that increasing call volume and under-resourcing, according to the Fitch analysis, MedStar crews are overworked and unable to consistently hit response-time goals.
Last summer, MedStar officials told city leaders that they’d need a significant subsidy to continue serving Fort Worth residents at the current level.
In the wake of that announcement, Fort Worth took several steps to stabilize the provider and scrutinize its future. To examine emergency services in the city, Mayor Mattie Parker created the EMS council committee, members of which are working with Fitch & Associates through April.
Council members also approved a budget with $4.2 million carved out for potential allocation to MedStar, to help the provider stay afloat while the study is ongoing. Ultimately, that money was not allocated, as the EMS provider was able to reach an initial agreement with JPS Health Network and the city to get reimbursed for medical care at area jails, making the city subsidy unnecessary.
At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here. Emily Wolf is a government accountability reporter for the Fort Worth Report. Contact her at emily.wolf@fortworthreport.org or @_wolfemily
This article first appeared on Fort Worth Report and is republished here under a Creative Commons license.