MedStar works to hold on to its improvements

FORT WORTH -- For the first time in years, the organization that provides ambulances for Fort Worth and much of Tarrant County is meeting one of its key goals: arriving on time to the most serious emergencies.

Now MedStar is working to solidify those improvements, even as budget pressure forces it to trim its work force.

MedStar's goal is to arrive at 90 percent of life-threatening emergencies within nine minutes. The company, which provides ambulance service for Fort Worth and 14 other area cities, has had problems meeting that goal since at least 2000.

MedStar met its goal from March to July, though, and its executive director tentatively believes the agency has turned a corner. In August, MedStar was just above the 90 percent goal in Fort Worth, and only slightly lower in the surrounding cities.

MedStar increased its staffing this year, adding 12 two-person "shifts." It is also working to deploy crews more efficiently. A computer program lets dispatch centers pre-emptively assign ambulances to the areas with the most calls.

"We turned it on in February, and the first full month was March. That was the first time we were above 90 percent," said Jack Eades, MedStar's executive director.

MedStar began as a consortium of cities that banded together to hire a contractor. The 15 cities cover 421 square miles and 881,000 people -- about half of Tarrant County's population.

The first two contractors hired by the MedStar board, Rural/Metro and American Medical Response, had trouble living up to the contract. The MedStar board, formally called the Area Metropolitan Ambulance Authority, fined them hundreds of thousands of dollars.

In 2005, the MedStar board opted to drop out of its contract with Rural/Metro and run the ambulance service itself. MedStar took over the ambulances and crews that had previously worked for Rural/Metro.

MedStar continued to have trouble with response times. In 2007, Fort Worth began allowing off-duty firefighters to work with MedStar to improve the on-time percentage.

Eades said MedStar's managers spent a lot of time adjusting to their new roles when they took over the system. Besides adding software this year, MedStar is having its supervisors spend more time on the street. And when an ambulance is late to a call, the supervisors are paged and can begin investigating the cause right away.

"It's the difference between being an air traffic controller and being a pilot," said David Shrader, a consultant with the Polaris Groups who prepared a report on the system for the Fort Worth City Council.

Shrader, who rode along with ambulance crews, reported that some of MedStar's paramedics seemed burned-out and disconnected from their patients. He attributed that to the transition that the managers and paramedics went through. Also, the crews typically work 12-hour shifts, and the work can be emotionally and physically demanding.

"They had a long painful period of learning how to run a high-performance EMS system," Shrader said. "I think some of the interaction with the field crews got lost."

MedStar has hired new middle managers, including an operations director, whom Shrader credited with helping improve morale.

'Frequent fliers'

MedStar has also been working to reduce the number of "frequent fliers" -- people who call 911 for routine illnesses.

"We're working with those folks to make them understand ambulances are a pretty expensive taxicab," said W.B. "Zim" Zimmerman, a Fort Worth councilman who serves on MedStar's board.

The system is still making enough money to cover its costs, but its funding sources are changing. Until recently, the system received substantial money from its member cities. Fort Worth contributed $1.6 million last year, and Haltom City had planned to increase its contribution to $250,000 a year. But both cities plan to cut their subsidies in the fiscal year that begins Oct. 1.

The city subsidies will amount to less than 1 percent of MedStar's budget next year, Eades said.

That means MedStar must charge customers more, particularly those with private insurance.

Only 15 percent of MedStar's patients have private insurance, but they provide 50 percent of the system's revenue. A large percentage have Medicare or Medicaid, but the federally funded programs' reimbursements are well below MedStar's cost of doing business.

"You can't check their insurance card before you pick them up," Zimmerman said. "When you get to the amount of uninsured they write off, it's unbelievable."

It's similar to the problem that nonprofit hospitals face in providing care to people who can't afford to pay the bills.

"It is happening across the country," said Tristan North, vice president of government affairs for the American Ambulance Association. "As cities face tight budgets and need to make necessary cutbacks ... a lot of the subsidies are being cut."

The upshot in Fort Worth and most cities that use MedStar is that patients will be billed up to $1,505 for each ambulance trip.

MedStar is also cutting five crews by eliminating vacant positions, Eades said.

Even people with private insurance could wind up owing hundreds of dollars for an ambulance, although Zimmerman said they can partly offset that by buying a separate insurance policy that covers ambulance charges.

Holding down costs

Tom Muir, city manager in Haltom City, said he elected to cut his city's $41,000 contribution to MedStar because he didn't think it was doing enough to hold down costs for his residents.

With "the subsidy we had, they were still getting big bills," he said.

Ultimately, the national healthcare overhaul might help, some experts say. The law requires most people to buy private insurance by 2014. If that happens, then the burden of providing ambulance service would theoretically be spread over more people, lowering the price per person.

Meanwhile, the ambulance association is working with Congress to increase the amount that Medicare and Medicaid pay for ambulance services, North said.

"It's kind of a guessing game to how it will all filter out," he said.

Mike Lee, 817-390-7539