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July 22, 2013 How Connecticut Works: Ambulance Services

CT’s ambulance services fragmented, consolidated

Photo | contributed EMTs Sean Norton and Lauren Golden work for Ambulance Service of Manchester, one of the major private ambulance companies in Connecticut.
Photo | Contributed Wayne Wright, CEO of Aetna Ambulance Service Inc. and Ambulance Service of Manchester, said his companies have grown 3 to 6 percent in recent years.

In Connecticut's world of emergency medical services, fragmentation is the name of the game.

It may not surprise many people in the Land of Steady Habits, where cities and towns often operate as their own fiefdoms, but nearly every municipality in the state has its own way of providing emergency medical transport services.

When the half-million or so 911 calls are placed each year by Connecticut residents, just who shows up to provide life-saving support depends on location.

Some cities, like Hartford, outsource ambulance transport services to private companies. In Wallingford, emergency medical transport services are provided in-house by paramedics employed by the town.

For other municipalities, like East Hartford, it's a mixed bag. They outsource ambulance transport services to a neighboring city, but use in-house paramedics.

The bifurcated system, experts say, is largely a result of an industry still in its infancy. Modern day emergency medical services only dates back to the 1970s, making it one of the youngest — and still developing — public services in existence.

Even still, Connecticut's hodgepodge approach raises questions about efficiency and cost effectiveness. As cities and towns face continual budget challenges, calls for regionalizing public services continue to grow louder.

“Oftentimes in Connecticut, people want to have their service in their own control,” said Daniel Savelli, operations chief of Windsor Volunteer Ambulance Inc. “But now I think the economic realities are starting to set in. There are a lot of emergency medical services organizations struggling to retain managers and funding to be a leader in public safety and patient care.”

Besides being fragmented, emergency medical service in Connecticut is highly regulated. The state Department of Public Health controls which companies or organizations can provide transport services in each city or town.

As a result, the state also has a heavy influence over the system's structure.

In Connecticut, emergency medical transport services are provided by various entities including municipal, volunteer, commercial and nonprofit organizations. The structure a city or town chooses rests on many factors including population size, call volume and cost.

In Hartford, for example, ambulance services are outsourced to two private companies: American Medical Response (AMR), which is the largest commercial player in the state, and Aetna Ambulance Service Inc.

That structure didn't develop by chance, said Andrew Jaffee, the city's director of emergency services and telecommunications.

During the 1990s AMR was the lead dog in Connecticut controlling nearly 66 percent of the commercial market after buying out many of its competitors. In 1999, however, AMR was forced to give up 40 percent of its Hartford market share after complaints emerged about the company's longer than average 911 call response times.

Rather than face an antitrust lawsuit from then Attorney General Richard Blumenthal, AMR decided to pare down some of its Connecticut holdings.

Now AMR controls the north end of the city, while Aetna Ambulance Service Inc. operates the south end of Hartford.

Jaffee said outsourcing saves city taxpayers money because they don't have to foot the bill for ambulance trucks, equipment or staff.

AMR and Aetna pay their own overhead with revenue generated from commercial and government insurers. Just like a hospital or doctor, ambulance companies charge for the medical services they provide.

Reimbursement rates are set by the state. Medicare also reimburses ambulance providers for certain services.

“If the city were to consider providing its own ambulance service, there would be an extremely high upfront cost,” Jaffee said. “Cost is a significant factor.”

Responding to 911 emergencies, however, isn't necessarily big business. Savelli said smaller, volunteer emergency medical service providers often face financial challenges because they don't always recover their full reimbursement. Emergency responders must provide transport services even if patients are uninsured and can't afford to pay.

Private companies, on the other hand, are much larger players in the more lucrative non-emergency transport service segment, where payment is guaranteed upfront, Savelli said. That includes services like transporting patients from a hospital to a rehab center.

“911 calls alone are usually not enough to sustain them,” Savelli said.

Wayne Wright, who is the president and CEO of Hartford's Aetna Ambulance Service Inc. and Ambulance Service of Manchester, said all ambulance providers are facing financial challenges as a result of declining Medicare reimbursement rates, which are down about 8.6 percent from a few years ago.

Still, that hasn't stopped his two ambulance companies, which are jointly owned by Hartford Healthcare and Eastern Connecticut Health Network, from experiencing 3 to 6 percent growth in recent years.

Combined, the two companies have a fleet of 48 ambulances and 228 employees, who respond to about 70,000 calls a year. They provide transport services to many Greater Hartford cities and towns including Hartford.

Wright also said that while many cities and towns provide emergency medical services differently, regionalization efforts have increased in the last decade or so, particularly after the consolidation wave that took place in the 1990s, when AMR aggressively bought out smaller ambulance companies in the state.

That shrunk the playing field from about 30 to 10 commercial ambulance companies in the state. It also means cities and towns are more widely sharing services from the same company.

“It has helped with regionalization efforts,” Wright said.

Meanwhile, the Windsor Volunteer Ambulance Inc. handles about 3,600 emergency calls each year. The third-party service provider is an independent entity that receives a $69,000 annual subsidy from the town. They have five full-time paramedics and 11 volunteers, and operate two ambulances during the day, which is peak demand for call volume, Savelli said.

Across the Connecticut River, the East Hartford Fire Department has a staff of about 50 paramedics handling 10,000 emergency calls annually. But the city's transport services are outsourced to Ambulance Service of Manchester.

East Hartford Fire Chief John Oates said the bifurcated structure has served the city well, keeping response times under five minutes and ensuring higher quality standards. City taxpayers, however, do pay more to cover the cost of employing paramedics. The city fire department's total budget is $12 million, which includes funding for paramedics.

“We look at it as a fundamental public service and something that we should be doing,” Oates said.

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