When somebody reported a man possibly having a stroke at the Palazzo recently, the Clark County Fire Department sent help. So did a local ambulance company.
A rescue unit from Clark County Fire Station 18 quickly arrived, joined moments later by the ambulance. Fire Department medics hurried in, examined the patient and brought him on a gurney into the hotel driveway. They helped the ambulance crew load the sick man, and within 10 minutes of the first unit's arrival, he was on his way to a hospital, an ambulance company paramedic riding beside him and monitoring his vital signs.
Over eight hours that Saturday, paramedics and emergency medical technicians from the station rolled six more times for medical calls, including a person asleep in the UNLV library who was incorrectly reported to 911 as "unconscious," and two others in which the principal problem appeared to be excessive consumption of alcohol or recreational drugs.
In each case, the Fire Department sent at least one paramedic and one emergency medical technician. In each case, the ambulance company sent at least one paramedic and one emergency medical technician.
Sending four highly trained specialists and two vehicles to virtually every 911 call for emergency medical service provides plenty of help to the victim, agree people on both the publicly and privately funded sides of the effort. Nationally, "dual response" is a popular model, and the variation in Las Vegas is said to be especially good.
But it's so expensive that some members of a task force charged with finding ways to rein in county spending suggested outsourcing the Fire Department's part to private ambulance companies, so taxpayers could quit paying the bill and the patients' insurance companies could cough up. In the other direction, North Las Vegas Fire Chief Al Gillespie has proposed that his men take over transport for the most urgent medical emergencies and bill for the service. The Las Vegas Fire Department has studied a similar option.
Estimating the potential cost savings of a different method is difficult.
But about that expense: For weeks after the Las Vegas Review-Journal requested information about the cost of emergency medical services, or EMS, Clark County officials stalled, and they still have not answered in detail.
Scott Allison, the county Fire Department spokesman, said, "The department does not separate costs" in a manner that would allow the cost of medical calls to be extracted. "All of our fire suppression personnel respond to any and all emergency calls," which he said could include fires, swift-water rescues, vehicle extrication, hazardous materials incidents and medical calls.
Fire suppression personnel are 651 of the department's 814 total. County spokesman Dan Kulin said the total wages and benefits package for fire suppression employees was $115 million last year.
Allison said 72 percent of the 122,111 calls the department answered this past year were medical.
From that a taxpayer could calculate the cost of firefighters responding to medical calls at $82.8 million -- 72 percent of wages and benefits for those personnel -- in unincorporated Clark County alone. In 2007, the last year for which the county has provided complete payroll data to the Review-Journal, the average employee of the Fire Department was paid some $113,000. (The head of the local ambulance company said his paramedics, who must be trained to the same county-established standards as Fire Department paramedics, are paid about $60,000 a year.)
The county personnel cost would not include the cost of purchasing, operating or maintaining the department's 25 medical/rescue vehicles or the additional wear and tear on 27 fire engines that also carry paramedics and respond frequently to medical calls.
County spokesman Erik Pappa said the county bought three medical/rescue units last year for $627,000, but the cost of one averages $275,000. Although the county did not say how long such vehicles can be expected to last, replacement cost of the medical/rescue fleet would be $6.9 million. New fire engines cost $593,000 each.
Of the 691 people who work for Las Vegas Fire & Rescue, 559 are in fire suppression and received $98.3 million in wages and benefits last year. Most are rotated during each shift between assignment to firetrucks and to rescue units. Last year the department reported that medical emergencies are roughly 90 percent of total call volume, so the medical/rescue share of the suppression employee cost was $88.4 million. The typical Las Vegas firefighter last year grossed about $110,000.
Besides pay, out of a total 2010 budget of $117.1 million, the Las Vegas department allocated $10 million for EMS expenses including supplies, drugs and training costs.
In North Las Vegas, Gillespie said his department also has a high ratio between medical calls and all others; of about 30,000 calls last year, he estimated, 75 percent to 80 percent were medical. The 221 employees of the department drew $32.3 million in wages and benefits, with $25.8 million of it going to the 178 employees in the fire operations division, which also answers medical calls; 75 percent of that figure is $19.3 million.
Gillespie feels that a high percentage of EMS calls, however, does not equate to EMS being responsible for a high percentage of the department's costs.
"Because we're dual response, it's a marginal cost between what we pay for firefighters and paramedics. We'd need as many firefighters just to provide basic firefighting, so we're giving the citizens a little better deal by using people we'd need anyway."
The average gross pay of a North Las Vegas fire employee last year was nearly $105,000.
In Las Vegas, North Las Vegas and Clark County, taxpayers don't finance the emergency transport end of the system, which is provided by private enterprise. But somebody, typically an insurance company, is billed for each transport, and the bill varies according to services used en route and the mileage driven; maximums are set by agreement with local governments.
John Wilson, general manager of American Medical Response, the valley's private emergency ambulance company, produced a report from his company showing the average invoice for transport on a 911 call was $916 in the fourth quarter of 2009. That's substantially lower than the average in many cities.
"In Monterey (Calif.), a typical bill is over $2,100," he said.
But about 33 percent of those transported after 911 calls here were uninsured, and only about 10 percent of the uninsured pay any part of their bill. Furthermore, the insured include those with Medicare or Medicaid, which pay substantially less than the usual bill. The company's actual collection rate has been running about 40 percent of billings. Financial realities such as those would create big consequences if emergency services were privatized. First-responder services by fire departments constitute a large taxpayer subsidy of the total EMS system. If any of the services now provided by fire departments were deemed essential and transferred to a user-paid system, doing so would require presenting users with bills -- possibly very large bills.
An article in a newsletter of the International City/County Management Association, written by several executives in private and public EMS, explained what would happen if an EMS system, which manages to collect 50 percent of its fees, lost its subsidies.
"If the ambulance service must collect, on average $270 per transport to fund its operations, and if a subsidy of $270 is provided, the rate that must be charged equals zero. But if no subsidy is provided, the average patient charge goes up to $500. ... Because it is unlikely that the full $500 will be collected."
In fact, fire departments are trying to take over some of the emergency transport, and perhaps charge for it as the private ambulance companies do. This is permitted in Nevada, said Wilson, because of a bill driven through the 2009 Nevada Legislature by firefighters' unions. Traditionally, local fire departments have transported patients only when an ambulance has not yet arrived and further delay would endanger the patient. The Clark County Fire Department said it has been transporting only 300 to 350 a year, but recently got county commissioners to approve an ordinance permitting them to transport up to 1,000.
And the North Las Vegas City Council is weighing a proposal from Chief Gillespie that his department transport all the "delta level" 911 patients, the most seriously sick or injured, and all traffic accident victims in the city. Gillespie claimed billing for the service could generate $1.6 million a year and save 16 department jobs from possible layoffs. Wilson countered that Gillespie's plan would cost at least a dozen jobs at his private company. Fire Department and ambulance company employees filled the council chambers Wednesday for a meeting on the issue, but the council continued the matter for discussion two weeks later.
The Henderson Fire Department does nearly all emergency medical transport in that city. According to Deputy Fire Chief Steve Goble, fire personnel decide whether patients need to be transported, but the patient decides whether to go because they will be responsible for the bill. The fees charged are about 5 percent less than private companies charge, he said. The department responded to 14,000 emergency medical calls last year and transported 10,788 patients to the hospital, or 77 percent of the calls. The rest didn't require transport or refused it.
Wilson said his privately run ambulance company transports someone from about 68 percent of the emergency scenes they visit, but adds that the difference might lie in the nature of Henderson versus the wider community.
"In a suburban community people tend to call an ambulance only when it's really needed," he said.
The reason might be that in an urban environment, a third party often sees an auto accident or a fallen person and makes the emergency call. In the suburbs, where less happens on the open street, the call is more often made by the injured party, who can better judge whether help actually is needed.
Las Vegas Fire & Rescue has a rule that each rescue unit must transport at least two patients per shift, but Las Vegas Chief Greg Gammon says a given unit does not always encounter that many who need transport, so there's no penalty for not meeting the goal.
Last year, when the possibility of a strike loomed in the private ambulance service, Gammon wrote a report analyzing the potential revenues and costs the city of Las Vegas would encounter if its Fire Department took over emergency transport entirely, concluding, "The revenue of 100 percent transport will outweigh any increase in cost by approximately $7.6 million annually."
But he said more recently the city isn't actively pursuing the idea.
"There are some cities where the fire department does 100 percent of the transport. ... That model wouldn't work in Las Vegas the way we are currently staffed because too many of our units would be at the hospital when we needed them."
Similarly, full privatization of EMS would present daunting challenges.
"If you had enough resources and enough people, of course, you could do it," Wilson said. "But if you take either side of this system away, there would be great impacts on the other side of the equation. Taking us out of the picture would be very harmful."
Contact A.D. Hopkins at adhopkins @reviewjournal.com or 702-383-0270. Contact Alan Choate at achoate @reviewjournal.com or 702-229-6435. Contact Scott Wyland at swyland @reviewjournal.com or 702-455-4519.