David Garrick
The San Diego Union-Tribune
SAN DIEGO — A key element in San Diego’s contract with its new ambulance provider is a set of stiff penalties for excessively slow emergency responses, which could help solve a problem that city officials have struggled with for years.
When the new provider, Falck USA, takes over later this year for American Medical Response, it will face a new kind of penalty the city hasn’t previously used.
AMR has been fined when its overall performance on response times haven’t met city criteria, but the company has never been penalized for individual emergency response times that far exceeded the city’s goals — no matter how egregious the failure.
But the new city contract with Falck includes a $5,000 fine every time an ambulance takes longer to arrive at an emergency than 24 minutes — which is double the city’s 12-minute goal for ambulance responses.
Fire-Rescue Chief Colin Stowell says those new fines, coupled with Falck’s commitment to increase ambulance operating hours by 20 percent, will boost overall service across the city when the company takes over and eliminate outlier response times.
“That’s the biggest financial difference in the new penalty structure versus the one we’re in right now,” Stowell said. “If you know you’re not going to make the 12-minute time clock, there’s no difference now in the cost whether you get there in 13 minutes or 25 minutes.”
Stowell said an analysis of response times for American Medical Response has convinced him that the $5,000 fines will be a significant disincentive for Falck.
“We didn’t get down to the exact dollar, but we do know it would have been in the six figures for sure,” he said, referring to what AMR would have had to pay if the new fines had been included in previous contracts.
San Diego presents significant response-time challenges for ambulances, with its sprawling suburban neighborhoods, meandering canyons and traffic congestion, but city officials say excessively long response times are still unacceptable.
The main motivation for the switch from Falck to AMR was the prospect of a boost in quality, especially better response times in ethnically diverse and low-income neighborhoods south of state Route 94. But the new penalty for excessively long responses applies in all neighborhoods.
The new contract, which the City Council approved last month after more than a year of analysis, also requires Falck to quickly determine what caused any excessively slow response, explain it to city officials and propose a solution.
“We also added a little more teeth to the language in what we call the ‘plan to cure,’” said Stowell, explaining that Falck must provide a written improvement plan within 15 days. “We got a little more defined in what is actually required.”
The contract with Falck also requires the company to be significantly more transparent regarding expenses, revenues and staffing than AMR was, he said.
“Our nose is going to be in their business,” the chief said. “We have a vested interest in their sustainability and their success, so we are asking for a lot more documentation.”
Unlike the city’s deal with AMR, the new contract requires frequent and detailed reports from Falck on such things as staff turnover, hours worked, vehicle mileages, billing collection rates, patient charges, cash flow and related information.
Stowell and Falck officials say this type of oversight will allow city officials to see potential problems before they materialize and possibly make constructive suggestions to make service better and more efficient.
AMR officials, who lobbied aggressively to retain the city contract, declined to comment.
The new five-year contract requires Falck to provide 1,008 hours of daily ambulance service. That’s a 20 percent increase from the 840 hours now provided by AMR, which had proposed a more modest increase to 888 hours in its effort to keep the contract.
While the City Council unanimously approved the switch to Falck, Councilwoman Marni von Wilpert expressed skepticism that the contract is written well enough for the city to have leverage over Falck for non-compliance.
Stowell agreed this week that Falck’s commitment to provide 1,008 hours could be relatively difficult to enforce.
“There is not a dollar figure associated with that, so that will be left to interpretation,” he said. “But that is another enforceable area where we can call them out, for either a breach of contract or plan to cure, and impose penalties.”
Stowell said he is confident Falck will be a great partner because the reputation of the company, which wants to become the dominant ambulance provider in California, is on the line.
“I think they are going to pull out all the stops,” he said.
Some other critics say the new contract should increase penalties for failing to meet aggregate response-time goals, which require ambulances to arrive within 12 minutes to at least 90 percent of the emergencies across the city and within 12 minutes to at least 90 percent of emergencies in each of the four geographic quadrants of the city.
The penalties remain a warning for a first offense, $30,000 fine for a second offense, $60,000 for a third offense, $120,000 for a fourth offense and $250,000 for a fifth offense.
Stowell said city officials considered increasing those fines but ultimately decided against it.
“There’s a balance there, because these are partners of ours in public safety,” he said. “Although we want these to be enforceable and something that motivates them to continue staffing so they can respond in a timely manner, we also don’t want to bankrupt them or cause problems for us because they’re not financially stable. We thought these were enough to correct the behavior without being too severe.”
Others have suggested San Diego return to a response-time model that divides the city into eight zones instead of four, which reduced the chances some neighborhoods would get neglected. The larger the compliance zones, the easier it is for an ambulance company to achieve response-time goals by making up for poor times in some neighborhoods with great times elsewhere in the zone.
San Diego experimented with eight smaller zones for a few years but then reverted to four larger zones in 2017 after complaints from AMR.
“It was very hard for an ambulance company to have a deployment model that covered those small areas,” Stowell said. “Gaps would start popping up all over the city.”
Stowell added that including eight zones in the request for proposals the city issued last year would have elicited proposals much less financially favorable to the city.
“We saw the headaches that the eight zones would bring, and we knew that the price to bid that would be astronomical,” he said. “With the traffic congestion our city sees, it would be very hard to keep that up. It just was not a sustainable model.”
Fewer excessively long emergency response times would also improve fire service in San Diego, because both a fire engine and an ambulance respond to most emergencies.
“Those are my folks sitting there at the scene of a traffic accident or with a medical patient awaiting an ambulance, so the quicker that ambulance gets there, my fire engine can go back to providing other services,” Stowell said.
The city is now in the middle of a six-month transition from AMR to Falck that is scheduled to conclude on Thanksgiving weekend in late November. Stowell said some early growing pains are probably inevitable, but that he expects things to be running smoothly by next spring.
This story originally appeared in San Diego Union-Tribune.
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