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Ronna L. Fickbohm Fletcher Struse Fickbohm & Marvel PLC 6750 N. Oracle Road Tucson, Arizona 85704 Telephone: (520) 575-5555 [email protected] Attorneys for Intervenor, River Medical, Inc.
BEFORE THE OFFICE OF ADMINISTRATIVE HEARINGS
In the Matter of:
GOLDEN VALLEY FIRE DISTRICT Applicant.
) ) ) ) ) ) ) ) ) ) )
Docket No. 2014A-EMS-0127-DHS (EMS No. 3820) INTERVENOR RIVER MEDICAL, INC.’S PROPOSED FINDINGS OF FACT AND CONCLUSIONS OF LAW (Administrative Law Judge: Tammy Eigenheer)
River Medical, Inc. (ARiver Medical@ or “RMI”), Intervenor herein, submits its
proposed findings of fact, conclusions of law and decision as follows:
HEARING: October 27, 2014 through October 31, 2014; November 3, 2014 through
November 5, 2014.
APPEARANCES: River Medical appeared through attorney Ronna Fickbohm. The
Arizona Department of Health Services (“ADHS”), Bureau of Emergency Medical
Services & Trauma System appeared through Assistant Attorneys General Laura Flores
and Patricia LaMagna. Applicant, the Golden Valley Fire District (“GVFD”) appeared
through attorneys James Belanger, Scott Bennett and Kathy Steadman.
ADMINISTRATIVE LAW JUDGE: Tammy Eigenheer
_______________________
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Evidence and testimony having been presented at the hearing in this matter and
considered by the Administrative Law Judge; all interested parties having been given a
full opportunity to present their positions, evidence and proposed findings/conclusions;
and based upon the entire record, River Medical submits that the following Findings of
Fact and Conclusions of Law, and Recommended Decision should be entered:
FINDINGS OF FACT AND CONCLUSIONS OF LAW
Background Information
1. On or about November 8, 2012, GVFD submitted its Application for
Certificate of Necessity (“CON”), under which GVFD requested authority to provide
immediate emergency (911) ground ambulance transportation services, both Advance
Life Support (“ALS”) and Basic Life Support (“BLS”), twenty-four hours a day, seven
days a week. The Application did not include inter-facility or convalescent transport
services (referred to collectively, hereafter, as “IFT”).
2. The proposed service area is already included within the larger service
area covered by River Medical’s CON No. 94, under which River Medical provides
immediate (911) and IFT transport services 24 hours a day, 7 days a week.
3. River Medical is a wholly owned subsidiary of American Medical
Response, Inc. (“AMR”).
4. AMR is a national medical transport company operated under and wholly
owned by its parent corporation, Envision Healthcare Corp. (AEVHC@).
5. AMR also owns Life Line Ambulance Service, Inc. the holder of CON
No. 62 (operated out of Prescott, Arizona).
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6. ADHS, through the Bureau of Emergency Medical Services & Trauma
System (ABEMSTS@ or “Bureau”), regulates ambulance services in Arizona.
7. ADHS issued a September 24, 2014 Notice of Hearing and Appointment
of Administrative Law Judge.
8. There, ADHS defined six issues for hearing, which issues are fully set
forth infra, p. 120, ¶47.
9. Pursuant to A.R.S. '36-2234, ADHS provided the required notice to other
ambulance services, or other interested parties, in the affected area.
10. On November 14, 2014, River Medical’s Motion to Intervene was granted.
11. No other person or entity sought permission to intervene or otherwise
participate in these proceedings.
12. During the hearing, no requests were made for permission to provide
public comments regarding the Application.
Exhibits
13. By stipulation and during the course of the hearing, the following exhibits
were admitted:
A. ADHS/BEMSTS:
Ex. 1, 3-21.
B. GVFD:
Ex. 1-18, 20-21, 23, 28, 29, 32, 35-38, 63-73, 76-77, 83, 87, 88, 94, 105-
108, 110, 117-119, 123, 124, 141, 147, 149-151, 153-156, 159, 163-165, 174,
176 and 177.
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C. River Medical:
Ex. 1, 2A&B, 3A, 7A&B, 8A-F, 13, 14B,F,H&I, 16A&D, 18A&B, 19, 23, 27,
32A-D, 33A, 34C-E, 35A, 38A, 39, 41A-C, and 43A-C.
Witnesses (Listed in order of presentation)
14. Paul Hewitt (first witness, 10/27/14, beginning at 00:20:00)1, GVFD’s
former Fire Chief). The following facts were established:
A. After twenty years with the Salt Lake Fire Department, Hewitt
spent one year as GVFD’s Fire Chief (between February 2010 and January
2011), before heading back to Utah (Park City), where he has been ever since
(GVFD Ex. 105 – Résumé, pp. 2-5).
B. Hewitt maintains a current paramedic certification. Id., p. 9.
C. His testimony specifically did not include any information regarding
GVFD or River Medical’s ambulance transport services subsequent to his
departure January 2011. He did not provide any facts relevant to the issues of
whether GVFD is currently “fit & proper” to operate an ambulance transport
service (from a clinical, operational, integrity or fiscal perspective), or relevant to
the issue of whether public necessity currently supports the addition of a second
ambulance transportation service provider to the area. He acknowledged he
cannot speak to GVFD’s proposed business model, financial model or anything
specifically related to GVFD or River Medical subsequent to his departure four
years prior. Id., 1:59:50; see also, id., 2:00:42 and 2:01:25.
1 Citations to the audio record will be given for each witness’ testimony by day and a.m. or p.m., and will include the hour:minute:second where the testimony begins and where the subsequently referenced testimony segments each begin.
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D. Hewitt’s twenty years with the Salt Lake City Fire Department did
not include any management or supervisory (or even EMT/paramedic)
experience in the ambulance transport service area (GVFD Ex. 105, pp. 3-5).
See also, 10/27/14 a.m., beginning at 1:10:13.
E. While promoting his personal opinion regarding a fire based
ambulance service being superior to a private entity run service, on cross-
examination, Hewitt acknowledge the model currently existing in the GVFD
area, that of having a public entity be the first responder to medical emergencies
and a private company then doing the ambulance transport, is common in
Arizona, Utah and nationwide. Id., 1:53:37.
F. While initially proposing the GVFD are is “unique,” Hewitt
eventually admitted he was unable to compare it to any other rural Arizona
community. Id., 1:28:00. He also acknowledged that the percentage of medical
responses done by GVFD cannot be called “unique” as compared to other rural
areas. Id., 1:31:34.
G. Hewitt agreed the location of an ambulance available to respond to
a call for transport service in GVFD could be outside of the fire district, for
example, adjacent to the freeway. Id., 1:46:12; see also, id., 1:45:12.
H. Hewitt also agreed what is most important in any ambulance
transport is the clinical care provided. Id., 1:558.
15. Marcus Osborn, Ph.D. (second witness 10/27/14 a.m., beginning at
2:18:15; first witness 10/27/14 p.m., beginning at 00:00:12):
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A. Osborn has mainly worked as a lobbyist (GVFD Ex. 65 – Résumé).
See also, 10/27/14 p.m., beginning at 00:08:30.
B. When he started his GVFD work, he had no training, knowledge or
experience in the critical medical issues involved in ambulance transportation
services. Id., 00:20:50. He also had no background in local or national
standards relating to ambulance services. Id., 00:21:11. His expert witness
consulting had historically been limited to the areas of elections and campaign
finance (GVFD Ex. 65, p. 3).
C. Osborn’s primary research interests have not included emergency
medical services (“EMS”), or ADHS’ regulation of such services. Id., p. 4. Other
than the GVFD proceeding, his Résumé indicates no expertise or experience
whatsoever in the areas of CONs or EMS. Id.; see also, 10/27/14 p.m.,
beginning at 00:22:59
D. On cross-examination, Osborn admitted the GVFD “Needs
Assessment” was his first project with regard to provision of EMS. Id., 00:15:15.
E. Osborn concluded “need” for the GVFD proposed service existed
because GVFD does not have a sense of itself except through the fire district,
GVFD is the anchor of the community, and there is a sense in the community
that they do not matter other than to GVFD. Secondarily, he referenced the
large size and scope of River Medical’s CON service area, and his perception
that there is a “need” for there to be a focus on GVFD’s unique and complex
needs. However, he did not detail what these supposed “unique and complex”
needs are. Id., 2:23:50.
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F. When questioned regarding “continuity of care,” Osborn simply
identified the Fire Chief’s goals, as opposed to any facts he independently
confirmed. Id., 00:00:30.
G. Osborn’s “Community Needs Assessment,” which GVFD’s
Application’s statement of public necessity is based upon (GVFD Ex. 1,
beginning at p. 123), was done in much the same way one would expect a
political survey to be done: it was designed to measure the local community’s
feelings and perceptions, as opposed to measuring concrete facts about existing
ambulance transport services. For example, while referencing a supposed
increased “risk of motor vehicle accidents” in the area, no statistics or
information was provided to demonstrate that this particular rural area has a
greater risk than any other rural area in Arizona. Id., pp. 128-129. In discussing
his research methodology, Osborn indicated that “Golden Valley Fire District
defines unmet needs in-part as the difference between the level of service
currently being provided and the needs as expressed by the population of
Golden Valley.” Id., p. 129. However, other than the attitudes and desires of
the GVFD community, no other “expressions” of the local population were
provided. For example, no statements of incidents where River Medical was
unable to respond to a call for ambulance transport services in a timely and
appropriate manner were included. GVFD Ex. 1, beginning at p. 123. Also, the
standard applied was based upon GVFD’s leadership’s belief “that the
community of Golden Valley is best served when there are three operationally
available ambulances in the District but at a minimum there should be at least
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two ambulances stationed and available in the District.” Id., p. 129. However,
the Assessment contains no facts demonstrating that reasonable and
appropriate ambulance transport responses cannot be accomplished with
ambulances that move in and out of the GVFD area, for example, a unit
stationed on the far west side of Kingman. Osborn simply adopted, with no
confirmation or analysis, GVFD’s “belief.” Id. He also accepted GVFD’s
definition of “under-deployment” as being “a condition where there were either
no ambulances or only one ambulance without an operational Golden Valley in-
District backup.” Id., pp. 129-130. He identified no facts to demonstrate this
would in fact be an under-deployment, including no facts showing River Medical
had been unable to provide reasonable and appropriate ambulance transport
responses on the rare incidents where it had no ambulances or only one
ambulance located within fire district boundaries. Id.
H. Osborn also relied upon data collected by a GVFD employee
known as Nicole Guerrero. Id., p. 130. However, Ms. Guerrero was not called
to testify, was established by GVFD’s Chief himself as an unreliable employee
whose errors had caused the fire district to have tax problems (see infra., p 52,
¶29DD) and was proven to have made many errors and false assumptions in
collecting her data (for example, see infra., p. 107, at ¶¶34O and P).
I. To assess River Medical’s response times, Osborn’s Needs
Assessment compared GVFD’s actual (first responder) response times to the
River Medical CON required minimums. No attempt was made to compare
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actual GVFD first responder response times to actual River Medical ambulance
transport response times. GVFD Ex. 1, p. 131.
J. The citizen survey Osborn utilized “was designed to assess
resident attitudes about the quality of the emergency response services
provided in the Golden Valley area and to assess the preferences for the
emergency response services.” Id., p. 132. No survey questions asked whether
the participant had experienced a delay in an ambulance transport response or
other such “substandard service” issues. Id., pp. 134-135.
K. The “Assessment” was also based upon letters from the business
community, none of which referenced any delayed response or other
substandard service issues, and all of which appear to have been based upon
the same form letter. Id., p. 135 and pp. 288-298
L. Osborn stated that the “relative opinions of Residents are
important factors in determining community need and the data suggests that
moving ambulance service to the Golden Valley Fire District has merit because
of the superior performance of the Golden Valley Fire District in terms of
customer opinions.” Id., pp. 137-138.
M. While Osborn’s discussion of the business community’s input and
support referenced certain concerns about River Medical, for example, training
and “hand-offs,” this also was opinion or “sentiment” based, as opposed to
referencing any specific facts indicating that River Medical’s employees are not
properly trained, that patient “hand-offs” are unusual in the EMS environment or
have caused any particular problems in GVFD historically, or that any other
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historic problems have been observed with River Medical’s services or
employees. Id., pp. 141-142.
N. Osborn identified Assistant Chief Ted Martin as a key player in the
GVFD’s implementation of an ambulance transportation service, along with a
not yet hired “new position of EMS Program Manager.” Id., pp. 148-149.
16. George Belokas (second witness 10/27/14 p.m., beginning at
3:03:40; first witness 10/28/14 p.m., beginning at 0:37:30):
A. Belokas prepared Appendix 6 to the Osborn “Needs Assessment”
(GVFD Ex. 1, beginning at p. 220).
B. His report was based upon radio traffic detailed on a spreadsheet
by GVFD employee Nicole Guerrero. Id., p. 221.
C. The River Medical response times he compared to GVFD
responses (id., pp. 223-224) measure time from dispatch to arrival (or 100% of
the time between when a call comes in to dispatch and the ambulance arrives);
the GVFD response times measure “alarm” time to arrival (a shorter period of
time, which does not start until dispatch trips the “alarm” at GVFD). See infra, p.
103, ¶34 I. As GVFD does not yet do ambulance transports, this was also a
comparison of first responder times to ambulance transport arrival times.
D. His report erroneously assumed that River Medical is required to
“file” its posting locations with ADHS. GVFD Ex.1, p. 226. See also infra., p. 24,
¶24G.
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E. His report assumed River Medical’s ambulances posted at these
“unfiled” posting locations were “not available” for calls in GVFD. Id., pp. 226-
227.
F. While documenting ambulance availability based solely upon
GVFD’s interpretation of River Medical’s radio traffic, and defining “availability”
as only occurring when there was a River Medical ambulance within the GVFD
(ignoring even those River Medical ambulances that might be immediately
outside of the GVFD boundaries), nowhere did the report identify a single call for
ambulance transport services where River Medical was unable to provide a
reasonable and appropriate response. Id., pp. 220-243.
G. Belokas did not testify to any prior CON or ambulance availability
experience.
H. Belokas agreed that depending upon the circumstances, including
the number of vehicles available to do a first response (versus an ambulance
transport response) and where those vehicles are located, one could expect a
first responder to be able to arrive at the scene of an incident quicker than a
fully-loaded and fully-staffed ambulance. He also understood that the River
Medical response times he was looking at were for actual ambulance transport
responses, and that the GVFD response times were first responder times only.
Tuesday, 10/28/14 p.m., beginning at 1:31:0.
I. In discussing the “level zero” concept, Belokas agreed that if an
ambulance was not usually located in the GVFD area, but was told by a
supervisor to move there because the area was down to one or zero
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ambulances, and if this ambulance then sat unused for three or four hours and
eventually left without taking a call, assuming there were no radio
communications relating to this movement, that ambulance would not show up
in his data as “available.” Id., 1:53:06.
J. Nicole Guerrero did not tell Belokas about the River Medical
supervisor unit that “floats” at times in the GVFD area without announcing its
presence via radio traffic, and did not tell him such unit would be available to
take ambulance transport calls. The existence of this ambulance availability
would also not show up in his data. Id., 1:56:30.
K. His conclusions regarding “unavailability” did include scenarios
where a River Medical ambulance was located in the GVFD area, but was
moving from its original post. For example, in discussions regarding a unit
stationed at a possible homicide scene, and another unit coming to relieve it, he
agreed that both of these units would have been considered unavailable. Id.,
2:08:25. Likewise, if an ambulance was dispatched to an out of area location,
he would have classified that ambulance as unavailable from the time of
dispatch, during the entire time it was traveling within the district. If an
ambulance outside the district were directed via radio traffic to go to a post
within the GVFD area, he would not have considered that ambulance “available”
until it radioed its arrival. Id., 2:43:20. This artificially assumed ambulances “en
route” from one location to another within the GVFD area were not available for
emergency responses.
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L. A certain amount of calls were “scrubbed” out of the data where
Guerrero did not capture dispatch or arrival time. Belokas agreed this could
move his numbers, either way, approximately 3%. Id., 2:19:06.
M. Also, the times utilized for GVFD responses were to the nearest
minute, seconds were not included, even though seconds matter in calculating
ambulance transport response times. Id., 2:22:01.
N. Belokas did not look at any 2012 availability or response times
other than the ninety day period selected by GVFD, and did not have any
information for 2013 or 2014. Id., 2:23:21.
O. Belokas did not reach any conclusions as to whether River
Medical was providing appropriate ambulance coverage or response times
within the GVFD area (see also, GVFD Ex. 1, p. 220). Id., 2:25:00.
P. Based upon the adjustments he did after authoring his report,
Belokas’ calculations for the GVFD first responder times were as follows:
77% within 10 minutes;
92% within 15 minutes;
100% (rounded) within 30 minutes (with three calls exceeding 30
minutes).
Similarly, his adjusted River Medical ambulance transport response times
were as follows:
70% within 10 minutes;
89% within 15 minutes; and
100% within 30 minutes (only one call exceeded 30 minutes).
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Id., 2:25:45.
17. Gerry Sternes (first witness Tuesday, 10/28/14 a.m., via telephone,
beginning at 00:01:56), Complex Administrator of the Arizona State Prison, Kingman.
Facts established:
A. Sternes testified that he supports GVFD’s CON application
because in operating the prison he likes as many options as possible, as many
resources, when it comes to emergency responses, for the benefit of staff and
inmate safety, and for safety of the physical facility itself. Id., 00:11:28.
B. The prison provides no fire service of its own; it contracts with
GVFD, and has no other reasonable options for fire protection. Id., 00:14:22.
C. While initially denying his letter (GVFD Ex. 1, pp. 295-296) was
based upon a form, when he was read the letter, Sternes agreed he would not
have come up with all of the language, would not have known who to address it
to, and GVFD would have provided him the basic information. Id., 00:16:40.
D. River Medical has been doing ambulance transports for the prison
for as long as he has been there and he has never had a complaint about the
quality of their service; he also has not experienced any associated security
issues. Id., 00:27:05.
E. There is medical staff on duty at the prison; all prisoners requiring
medical treatment are not necessarily removed for outside care. However, if an
inmate does require transportation to a hospital’s emergency room, prison staff
will transfer care of treatment to the medical professionals doing the transport.
Once at the emergency room, the transporting crew will then transfer care to the
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emergency room staff. Once at the emergency room, it is possible the inmate
would be moved to intensive care, or a regular hospital bed, adding another
“hand-off” or transfer of the patient to different medical professionals. Sternes
has no concern about the inmate’s well-being because of these transfers or
“hand-offs,” he does not think any of these would compromise the inmate’s well-
being. Id., 00:28:15.
F. River Medical has participated in training with the prison, including
the training done for inmate transfers. River Medical has never declined an
opportunity to participate in joint training and the prison has a good, professional
relationship with River Medical. Id., 00:32:50.
18. Mark Vanik (second witness, Tuesday, 10/28/14 a.m., beginning at
00:38:45). Environmental Safety Coordinator for NuCor Steel and member of GVFD
Board for three and one-half years:
A. Because of the natural gas line running through the NuCor
property, and the dangerous nature of what it does, NuCor contracts with GVFD
for emergency responses (in case of earthquakes, tornadoes, etc.), fire service,
hazard services and safety training. Id., 00:41:20.
B. Also, because of the nature of NuCor’s business, it is bound by a
variety of state, local and federal regulations, including OSHA; NuCor can either
satisfy these safety compliance regulations itself, or contract with an outside
agency, which it has chosen to do (GVFD). If it did not contract with GVFD, it
would need to take care of this compliance in-house. Id., 1:09:20.
C. River Medical has participated in training at NuCor. Id., 00:44:19.
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D. When asked what issues led to NuCor’s decision to have some of
its employees trained as EMTs, he reference a possible heart attack situation at
NuCor, where he believed it took 30 minutes for River Medical to respond. Id.,
00:42:15. Upon cross-examination, he stated this occurred on March 20, 2012
at approximately 1:00 p.m. Id., 00:59:35. The response actually took 15
minutes. RMI Ex. 43A.
E. Vanik also testified to an incident occurring at the Off Road
restaurant on Highway 68, close to a River Medical ambulance station (which he
characterized as “kitty-corner,” approximately one quarter mile away). He
related that an elderly woman had fallen and had gashed her head, someone
other than himself called 911, it took 5 to 10 minutes for the fire department to
show up and get the woman to her feet., and she was fine when the River
Medical ambulance arrived approximately 5 to 10 minutes after the fire
department. She refused transport. He was certain that the ambulance had
come from the nearby station. 10/28/14 a.m., beginning at 00:48:20. On
cross-examination, he stated this incident occurred in approximately June or
July 2011, at approximately 7:00 or 7:30 p.m. He agreed fire district records
would exist for this call, but admitted he had not pulled those. Id., 00:57:25. His
recollection was shown to be in error. River Medical arrived over 1 minute
before GVFD. See, RMI Ex. 43B and C.
F. A third “incident” related by Vanik involved his wife, who developed
severe stomach pains at approximately 3:00 a.m., leading to a 911 call for
ambulance transport. He testified the fire department arrived 10 minutes later,
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his wife wanted to leave (for the hospital), but had to wait for the ambulance,
which took 20 minutes to show up. 10/28/14 a.m., beginning at 00:50:45.
However, on cross-examination, when presented with a redacted copy of the
River Medical record relating to the call (RMI Ex. 33A), he agreed that the
closest River Medical sub-operation station was approximately 10 miles from his
house, and that according the records, the ambulance arrived within
approximately 13 minutes of being dispatched, not 20 minutes. He also agreed
that the fire department only did basic life support treatment, and that it was
River Medical that initiated the advanced life support care. Id., 1:01:13 (and
continuing at 1:06:06 after ruling on objection).
G. Vanik also acknowledged that GVFD Board support for the CON
pursuit is not unanimous, one existing (not up for re-election) Board member
opposes the CON. Vanik’s seat is up for election in two years. Id., 1:11:28.
H. During the past approximately six years, GVFD has had four
different fire chiefs. The current Chief has served for approximately two years,
Chief Hewitt before him for one year, the prior chief (Rudy Balboa) for less than
two years, and before him Chief Nystead. Id., 1:17:05.
I. With regard to GVFD’s employment of O’Donahue, Vanik testified
the Chief acts at the Board’s direction, which dictates policies and procedures.
The Board can terminate the Chief’s contract at any time (with pay) and the
Chief can terminate whenever he wants (without any penalty). Id., 1:18:45.
J. Upon questioning by ADHS/BEMSTS, Vanik stated that the
incident involving the NuCor employee involved no first responder. Because
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NuCor has employees who are EMTs, they only requested an ambulance. They
have not had to call for any ambulance transport since that call in 2012. Id.,
1:21:03.
19. John Sutherland (third witness, 10/28/14 a.m., beginning at 1:26:29),
mechanic for GVFD, established the following facts:
A. Sutherland’s expertise is all as a mechanic. He has no ambulance
operational or clinical expertise to offer in support of an ambulance transport
service operation (GVFD Ex. 106 – summary of work history).
B. GVFD currently has two used ambulance vehicles housed at
Stations 11 and 13. 10/28/14 a.m., beginning at 1:49:00.
C. Station 12 is always the second busiest station, but ambulances
are kept there. There is no room to house an ambulance or crew at Station 12.
Id., 1:51:08.
D. Sutherland is a one man operation; there are no other GVFD
employees who provide mechanic services. His only support is inmate labor
provided on a part-time basis. Id., 1:50:10.
E. Tony Demaio is a firefighter with GVFD. Id., 1:52:10.
F. The two ambulances GVFD has are from 1998 and 2002. Id.,
1:52:45.
20. Earlene Mahar (fourth witness 10/28/14 a.m.; beginning at 1:56:16), a
resident of GVFD since approximately 2011, testified to an incident involving her
boyfriend and GVFD Chief O’Donahue rescuing an elderly woman from a fire - which
led to heroism awards; and with regard to ambulance service, testified:
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A. An incident occurred December 26, 2012 involving her father-in-
law, whom she described as a “very large” man, where 911 was called. She
stated that GVFD arrived first, stabilized him, and then River Medical arrived,
entering the doublewide trailer with a gurney, and with their ambulance set up
and ready to go. Because of the tight corners in the residence, her father-in-law
actually walked out to the ambulance. The ambulance departed the house
before she and her boyfriend did, and she was surprised when they passed the
ambulance parked by the side of the road. She and her boyfriend arrived at the
Kingman hospital before the ambulance. Id., 2:07:10.
B. At the hospital, she asked as nurse if she could speak with
someone from the ambulance company. That person told her the ambulance
had started to overheat (which was resolved), but they also had to start an IV.
Her unhappiness with the situation is she felt like River Medical’s employees
were not kind and sympathetic enough. Id., 2:15:54.
C. On cross-examination, she admitted she lives on a bumpy road
(id., 2:18:20), and she did not make a complaint to anyone at the hospital other
than the nurse she asked to direct her to the ambulance employees or any one
from either River Medical/GVFD (id., 2:20:20). She also testified that her house
is more than 13 miles from the Kingman hospital (her work is 13 miles away and
the hospital is a little further). She conceded that an 18 minute trip, for the
ambulance, sounds about right. Id., 2:19:0.
D. Earlene Mahar, at the time of her testimony, was an active
candidate for the GVFD Board. Id., 2:23:08.
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21. Linda Vanik (testified fifth on 10/28/14 a.m. beginning at 2:24:20), wife of
Mark Vanik, testified to her appreciation and support of the GVFD firefighters.
22. Jim Haynes (sixth witness on 10/28/14, beginning at 2:27:45), President
and CEO of Behavior Research Center, company that helped develop and administer
survey included in Osborn’s “Community Needs Assessment.” The following facts
were established:
A. The primary purpose of the survey was to give the GVFD Board and
management guidance as to whether or not the public they report to was on the
same page with them; it was designed to measure their attitudes toward the
services provided by GVFD and by River Medical. Id., 2:33:10.
B. To develop the questionnaire, Haynes was provided with a general
outline done by Osborn, whom he has worked with before on different projects.
Osborn “had a good idea of what the district wanted . . .” Id., 2:40:30.
C. All questionnaire facts were provided by Osborn. Id., 2:43:11.
D. Tables 3 and 3A capture attitudes of individuals surveyed as to
interactions with River Medical. 83% rated this as “excellent to good,” which
Haynes called “very good numbers.” 10/28/14 p.m., beginning at 00:21:10.
E. Both the written and telephone surveys were structured to
encourage responses. Many of the written questions did not include “I don’t
know” or “neither” as an option. Likewise, the questions programmed into the
computer for the telephone questionnaire did not offer the person asking the
questions the response option of “neither” or “I don’t know.” With the telephone
survey, if a responding person said one of these things, there was a field to put
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the information in, but the person administering this survey did not affirmatively
tell the participant these were options. Id., 0:25:55; see, also id., 0:35:40.
F. Haynes’ experience with political studies is that the popularity of
fire departments is “sky high.” Id., 0:30:50.
G. Haynes agreed that he was not testifying the survey results
established any deficiency in the emergency medical services system currently
in place in GVFD; in fact, he stated that based upon the findings of the study, his
answer certainly would be no. Id., 0:34:25.
H. Haynes characterized the GVFD survey as “relatively expensive,”
estimating it cost between $20,000 and $25,000. Id., 0:34:50.
23. Michael Hartsig (testified first on Wednesday, 10/29/14 a.m., beginning
at 0:02:10), the Plant Manager for Griffith Energy, established the following:
A. Griffith contracts with GVFD for both emergency services (fire
suppression and hazardous material responses) and regulatory compliance
(including inspections and training). This involves GVFD going to Griffith
approximately once a week. Id., 0:06:10. This includes compliance with OSHA,
and state and local regulations. Griffith’s choice is to either provide these
services itself or contract with an outside entity. As Griffith is not located within
the GVFD district, GVFD would not provide fire protection or hazardous material
responses unless Griffith contracted with it. Id., 0:14:50. If Griffith did not
contract with GVFD for that fire/hazardous material response protection, it would
have to contract with some other company. As River Medical only provides
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ambulance transport services, River Medical would not be an option. Id.,
0:17:00.
B. Hartsig supports GVFD’s Application because of their existing
relationship and because the services they provide are very important to him.
Id., 0:12:00.
C. The August 27, 2012 letter he wrote in support of GVFD’s
Application (GVFD Ex. 1-0288) was built off of a “template” that GVFD provided
to him, and that he pretty much left intact. Id., 0:09:58.
D. With regard to his concern about “hand-offs” as stated in the letter,
he references his own employees’ handing off information to each other, and the
risks associated with the same. Id., 0:12:40. However, he eventually agreed
that he is not familiar with the training or documentation used by medical
professionals in connection with medical transfers (such that he really cannot
speak to the same). Id., 0:21:40.
E. Likewise, during his entire tenure with Griffith (a little over four
years), he has only needed to look to GVFD once in order to do a hazardous
material response and Griffith Energy has never required an ambulance
response. Id., 0:19:00.
F. Hartsig had no negative comments regarding River Medical; in
fact, he has no experience with River Medical. Id., 0:20:35.
24. Ithan Yanofsky (second witness, Wednesday, 10/28/14 a.m., beginning
at 0:25:40), Deputy Chief for BEMSTS, established the following facts:
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A. It takes a certain number of employee hours to staff an ambulance
twenty-four hours a day, seven days a week: it takes 8.4 FTE (full-time
equivalents), which is separate and apart from the number of employees
required. Staffing three ambulances for twenty-four hours a day, seven days a
week, would require approximately 25.2 FTE hours devoted purely to the
ambulance transports (as opposed to fire services). Id., 0:51:20.
B. When looking at an applicant’s financial situation, whether or not
the ambulance transportation service has substantial debt is not the issue that is
of concern, what is of concern is the ability to pay that debt. Id., 0:55:20.
C. The Bureau understood that GVFD had approximately $3 to $4
million in available funds (at the time of the Application). Id., 0:57:30.
D. GVFD did not include a subscription service program in its
Application. Subscription services are like insurance; this is a contract under
which a person pays a set amount which will then cover ambulance services
over and above a certain amount (it varies by contract). Id., 1:30:30.
E. The Application shows a loss of over $894,000. The Bureau’s
analysis showed a loss of approximately $762,000. Because of the $3 to $4
million that the Bureau understood GVFD had on hand, this loss was not
considered to be an issue. Id., 1:17:15.
F. In the Bureau’s substantive review letter (EMS Ex. 9, at p. 2), it
asked GVFD to “justify the need for 24.8 [FTE] positions to perform a relatively
low number of runs [1,100].” The “relatively low” qualifier to the transports
number was based upon the approximate number of FTEs required to maintain
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three full-time 24/7 ambulances – somewhere between 24.8 and 25.2. GVFD
never gave the Bureau a response to this inquiry. Id., 1:22:20.
G. The location of an ambulance transport service sub-operation
station must be submitted to the Bureau, and any changes must be updated
approximately thirty days in advance. However, this is distinctly different from
an ambulance posting location; a posting location is a place where an
ambulance service decides it would be a good idea to put an ambulance in
order to respond to the call volume. Posting locations change and do not have
to be filed or reported to the Bureau. Id., 1:42:15.
H. As part of BEMSTS’ file, it has copies of communications
submitted to the Director regarding GVFD’s Application. These were admitted
by stipulation as EMS Ex. 16 – 20 (id., 1:44:53) and are as follows:
Ex. 16 – Golden Valley resident Sherri Borden emailed the
Director on May 23, 2014 stating her belief that allowing GVFD a CON
“would be a mistake for the citizens in Golden Valley.” As an almost
twenty year resident of Golden Valley, she has used both River Medical’s
services and GVFD’s services. She observed that River Medical “has
always been timely & sometimes even shown up before the fire dept. has
been on scene.” She thinks that having the fire department running an
ambulance service will only drain GVFD resources. She summarized that
“[i]t’s not broken don’t fix it.”
Ex. 17 – Bernice Stone-Martin emailed the Director on June 12,
2014, as a Golden Valley taxpayer. Her response to the Application was
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that she is “appalled.” She thinks the CON Application is “unnecessary
and wasteful. . .” Through listening to her own personal radio, she has
heard many calls where River Medical was first on scene. She observed
that “[w]ith there only being three stations and 7 fire personnel to cover
220 square miles plus any mutual aid calls that are needed, it would be
detrimental to our valley to have our own ambulance service. This would
take service away from the citizens leaving longer response times to
emergencies as we would have firefighters/paramedics tied up with
transporting patients.” She observed that there already have been
“numerous occurrences” of fire responses coming from further away due
to stations being tied up on other calls. She believes having GVFD
provide ambulance services “would make this situation much worse.”
She is concerned about the fiscal impact. She does not want the added
expense. Her belief is that the Application “is for personal gain and
notoriety for Thomas O’Donahue and not what is best for [the] citizens of
Golden Valley.”
Ex. 18 – Rhonda Brooks emailed Director Humble on June 14,
2014 in her capacity as a Golden Valley citizen (not as a Golden Valley
Board member, which she also is). She observed that the “taxpayers of
Golden Valley currently enjoy the best of two worlds: River Medical who
provides our ambulance service, and train paramedics, as well as our
own beloved firefighter paramedics.” If the fire district were to take over
ambulance service, they would lose half of that public safety protection.
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Observing that Golden Valley is not wealthy, she also stated that the
taxpayers “do not currently pay taxes to subsidize the ambulances. Only
people who use the service, have to pay for it.” She also observed that
River Medical sells a subscription service for $116.51. She characterized
River Medical as “good stewards to our community” and observed that
Golden Valley cannot currently afford to pay more taxes to support a
second ambulance service.
Ex. 19 – Lovelle Barnett emailed Director Humble on June 16,
2014. Barnett is a twenty-five year resident of Golden Valley and
opposes GVFD’s Application for CON. Stated concerns include the used
ambulances GVFD currently has, the district’s dirt roads, the fact of
GVFD using uncertified (as a mechanic) convict labor on ambulances,
River Medical offering a yearly subscription service while GVFD will not,
the opinion that a greater burden will be placed on taxpayers and the
concern that if GVFD is transporting a patient to a hospital, there will be
“less boots on the ground” in district (less fire personnel). This is contrary
to public safety. Also, the survey completed by the district was not fair to
River Medical or the fire district: most people could not honestly answer
most of the questions, as they do not interact daily with either one.
O’Donahue’s forwarded response email confirmed what Osborn testified
to: “The survey was designed to draw out the feelings of [the Golden
Valley] community that was pertinent to the EMS services provided to the
community.”
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Ex. 20 – Tony DeMaio emailed the Director on June 19, 2014
(GVFD witness Sutherland, supra, testified DeMaio is a GVFD firefighter).
DeMaio also is a resident since 1989 and his family/extended family has
been in the area since the 1960s. He thinks the CON is a “very bad idea
for Golden Valley.” His primary reason is that “the District will not be able
to provide the same level of service as the people are getting now.”
DeMaio related that the CON “fight started when a former Board member
was very upset when he was called about his ambulance bill…,” which
fact was “stated to [him] personally by the board member…” He believes
the taxpayers are being misled by the Board members and district
administration. He related that the district’s two current ambulances are
used. The air conditioning does not work in one of them and the second
had been out of service “for quite some time” (and was still out of service
as of 6/18/14). He related problems with that vehicle. He stated that the
second busiest station in Golden Valley, Station 12, does not have room
to park an ambulance and cannot accommodate additional personnel
without remodeling. “As a resident and taxpayer, [DeMaio is] confident
and happy with AMR providing ambulance service in Golden Valley, [and
is] also happy to not have the additional tax burden of the ambulance
service on [his] fire district.”
25. Lawrence Prudhomme (third witness, Wednesday, 10/29/14 a.m.,
beginning at 2:00:19 and then continuing - after a witness was taken out of order -
10/29/14 p.m., beginning at 1:57:50; also testified on rebuttal, Wednesday 11/5/14
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a.m., beginning at 00:20.04), CPA hired by GVFD to prepare its Ambulance Revenue
and Cost Report (“ARCR”). The following facts were established:
A. Witness had no prior experience preparing an ARCR. 10/29/14
a.m., beginning at 2:02:05.
B. To come up with GVFD’s proposed rates, he and GVFD looked at
the surrounding fire districts, which were “all over the map.” They selected Lake
Mojave Ranchos as being most proximate and similar in area/land mass. They
also looked at River Medical, as its rates had been approved for its entire
service area. As Lake Mohave Ranchos was lower, they decided this would be
better for the taxpayers. Id., 2:45:30.
C. The mileage rate came from looking at River Medical and Lake
Mohave Ranch, and averaging the two. Id., 2:50:35.
D. Prudhomme’s financial calculations, and the ARCR projections,
were based upon GVFD doing 1,100 transports, which he understands as being
100% of all the 911 generated (emergency) transports in the GVFD service
area. Wednesday, 10/29/14 p.m., beginning at 1:58:15.
E. Prudhomme also assumed the call volume would increase at the
rate of 9% per year. However, in looking at 2013, the actual volume was
approximately 900 transports, meaning the call volume actually decreased.
Prudhomme acknowledged this would impact his financial projections (but never
testified to what that precise impact would be). Id., 2:00:00.
F. Prudhomme did not do anything to update the Medicaid/Medicare
reimbursement rates from what they were in 2012. Id., 2:05:01.
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G. His numbers also assumed payment of 100% of the AHCCCS
claims, he did apply any risk (for non-payment) factor. Id., 2:06:09.
H. His self-pay collection rate of 60% was an “extrapolation” as
opposed to being based upon any comparable data. Id., 2:07:45.
I. The Medicare co-payment risk was looked at, but he did not factor
this in either. Id., 2:09:30.
J. While GVFD submitted its final version ARCR in 2013, at a time
when Medicare sequestration was in effect, Chief O’Donahue did not tell him
about sequestration (which he learned about just hours before his testimony), or
that it should be taken into consideration. Id, 2:09:50.
K. His calculations did not take into consideration the GVFD service
area’s “super rural” (Medicare) status, including the fact that because of the
annual re-evaluation of this rate by Congress, existing rates are at risk. He does
not know whether this has any impact on his calculations. Id., 2:20:17.
L. The additional employees that GVFD intends to hire to support the
ambulance transport operation will not be dedicated 100% to ambulance
transports; they will be cross-trained for fire duties. Id., 2:25:45.
M. GVFD looked at purchasing two new ambulances, and then
decided to simply buy one now, and one later. However, GVFD’s operation’s
plan involves four ambulances – three always fully staffed and one available for
repairs/training. Id., 2:27:35. The ARCR does show four on its depreciation
schedule, but these are for used ambulances, not new. Id., 2:29:35.
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N. The evolution of GVFD’s general fund was discussed to include
the following:
- Calendar year 2011 (based upon GVFD Ex. 13)
shows taxes as 92% of revenue (p. 9), excess
funds of $914,751 (Ex. 13, p. 16), and a general
fund with approximately $3.8 million. Id., 2:33:12.
- Calendar year 2012 (based upon GVFD Ex. 14),
there were excess funds of approximately $27,000,
which were adding to the general fund. Id., 2:34:30.
- Calendar year 2013 (based upon GVFD Ex. 15),
shows less than 1% of the GVFD calls involved
hazardous materials (p. 11), a revenue deficiency
of over $1 million (p. 23), which money depleted
the general fund to $2.76 million. Id., 2:35:50.
- There are no audited 2014 numbers out yet and he
he has no information about the status of the
general fund. Id., 2:34:20.
O. Prudhomme did not know anything about whether or not a tax rate
increase was contemplated by GVFD or what its required expenditures to
support fire services would be in the near future. Id., 2:3945.
P. While Prudhomme considered Lake Mohave Ranch’s rates and
charges in helping set GVFD’s rates and charges, he was unaware of that fire
district’s current financial status. Id., 2:45:00.
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Q. Based upon Lake Mohave Rancho’s ARCR reportings (GVFD Ex.
94), they have been balancing their ARCR reporting with local funding (tax
monies) until the 2012-2013 calendar year when they stopped showing that, and
simply reported a loss of $198,000. Their stated transport numbers and losses,
by fiscal years (there was no fiscal year 2010/2011) were as follows: 08/09 –
435 transports, loss of $841,796, more than $1 million spent in local support to
break even; 09/10 – 548 transports, loss of $1.337 million, balanced with local
funding; 11/12 – 605 transports, loss of $1.1 million, covered with taxpayer
subsidy; 12/13 – 515 transports, loss of $198,000. Id., 2:45:30. See also,
GVFD Ex. 94, pp. 2, 3, 6, 8, 13, 14, and 67-69.
R. Prudhomme has no knowledge of what has recently happened to
Lake Mohave Ranchos Fire District. 10/29/14 p.m., beginning at 2:50:00.
S. When asked by GVFD’s own attorney, Prudhomme testified that if
GVFD receives a CON, the intended deployment is to place one ambulance at
each of the fire district’s three stations so that the nearest ambulance can be
deployed to a call. The fourth ambulance will be “backup,” in case one of those
three goes out of service, requires routine maintenance, etc. Id., 2:58:09.
T. Prudhomme is not sure what has happened to the billable
transport numbers (decreasing, becoming stable, etc.) since did his calculations.
Id., 3:1:12.
U. On rebuttal (Wednesday, 11/05/14 a.m., beginning at 0:20:04),
Prudhomme presented GVFD Ex. 176 and 177, a recalculated “break even”
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presentation. In doing so, he changed his direct testimony that some
ambulances might be EMT only staffed. Id., 0:33:25.
V. In GVFD’s operative ARCR (GVFD Ex. 154, at Bates 00004, p. 2
of the ARCR), at line 12, the wage/payroll/employee benefit figure was
approximately $1.5 million. This included four new EMTs and a 68% allocation
of existing personnel. In his “break even” analysis, that figure has been
changed to $195,466 – wages and benefits for just the four new EMTs. Id.,
0:34:39.
W. Prudhomme understands GVFD’s operations model includes three
ambulances operating 24 hours a day, 7 days a week. Id., 0:38:00. He
understands this will take eighteen employees (bodies) to cover. Id., 0:41:35.
The information regarding employee availability to staff this operation model
came from GVFD, not from him. Id., 0:44:39.
X. When questioned about how the 68% allocation of existing staff
could be entirely subtracted out given GVFD’s first responder obligations,
Prudhomme agreed that ambulance transport duties would take longer than
being a first responder. Id., 0:46:00. Initially, he testified that one of GVFD’s
three ambulances would transport the patient, and the two other ambulance
units would be available to be the first responder. Prudhomme was then asked
how this would allow him to not include the 68% allocation for existing personnel
in his “break even” analysis. Id., 0:52:36. He then agreed that only one
ambulance unit would respond to the scene of a call, doing both the first
response and transport. Id., 0:55:26.
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Y. The result of this new operations model would be that of having
only two trained medical professionals on scene of a call instead of four. Id.,
0:56:19.
Z. While Prudhomme included a footnote reference to a Safer Grant
in the ARCR calculations (noting the possibility of this covering the cost of new
hires), he acknowledged he knows nothing about the Safer Grants, or the
likelihood of GVFD getting one. Id., 0:57:00.
AA. Prudhomme agrees Rich Bartus has more industry experience
than he does in evaluating the reasonableness of a proposed ambulance
service model. Id., 1:02:07.
BB. Prudhomme cannot state he knows GVFD will be physically
capable of performing all normal fire and hazard services its taxpayers expect,
while at the same time doing the 100% of transports its proposed business
model is based upon. He can only speak to the financial analysis, which relies
upon operational information provided to him. Id., 1:03:00.
26. Todd Jaramillo (fourth witness, 10/29/14 a.m., beginning at 3:04:40),
Ambulance Services Manager for BEMSTS, established the following facts:
A. Other than the overlap of River Medical’s service area (with
essentially all of the proposed GVFD service area), there is only a “slight” or
“tiny piece” overlap with Mohave Valley’s CON service area and an insignificant
overlap with Bullhead City’s CON. Id., 3:09:35; also 3:14:39.
B. The GVFD maps do not show the GVFD service area segments
that run along Interstate 40, to the south, and Highway 93, to the north, to scale.
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They are made larger so they are easy to see as if drawn precisely, they would
almost mirror the highway itself, as the proposed service area parallels those
sections of the highway to a small extent only. Id., 3:13:10; see also, id.,
3:25:27.
27. John Sinclaire (first witness, 10/29/14 p.m., beginning at 00:00:05), Fire
Chief with Kittitas Valley Fire and Rescue, testified that in his opinion a fire-based
ambulance transport service is preferable to a private-based ambulance service. In
connection with his stating this preference, the following facts were elicited:
A. According to his Résumé (GVFD Ex. 71) and testimony, Sinclaire
has no management experience outside of fire protection or a fire-based
ambulance system (no private entity managerial experience). Id., 0:27:00.
B. Sinclaire has interacted with AMR employees, including “upper
echelon” management and “their experts,” has worked with a number of AMR
private companies on task forces (id., 0:13:20), but had nothing negative to say
about either River Medical or any other AMR company.
C. Sinclaire knows Chief O’Donahue from their service on the
Washington State Fire Chief Board of Directors only, and from that limited
experience has a good opinion of him. Id., 0:15:15.
D. While Sinclaire had abstract criticisms, or scenarios of possible
problems associated with a private company-based ambulance transport system
(id., 0:49:00), he did not testify to any problems existing within the GVFD
proposed service area, with River Medical’s operation in general, or to any
specific incidents of system failure or other substandard performance by River
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Medical. His testimony did not identify any “need” existing in the proposed
GVFD service area.
E. Sinclaire has no experience with Arizona’s regulatory environment
(ambulance) and his only direct Arizona experience was years ago when he
consulted with the Northwest Fire District about fire service. Id., 1:13:10.
F. Sinclaire has no personal experience with River Medical, does not
know whether it serves its area by virtue of a contract, knows nothing of its
commitment to its public or its responsiveness, does not know anything about its
employees’ experience or training, and is not saying that because it is a private
entity, the community it serves is “at risk.” Id., 1:14:20.
G. Just because River Medical is a private company, does not mean
it is unresponsive to its communities’ needs. Id., 1:16:45.
H. Sinclaire agreed he was not testifying that just because an entity is
public, for example, a fire district, it will be able to run an ambulance service (not
every public fire district will necessarily be able to do this). Id., 1:17:00.
I. Sinclaire acknowledged that he was not testifying that he knows
enough about either GVFD or River Medical to be able to say that dynamic
deployment is not appropriate for that service area. Id., 1:19:35.
28. Rich Bartus (first witness, 10/30/14 p.m., beginning at 00:01:30) AMR’s
Regional Operations and Finances Officer (for AMR’s south region), in addition to
establishing his financial and operations oversight of approximately 55 operating
business units that generate approximately $440 million in revenue, based upon
approximately 1.1 to 1.2 million ground ambulance transports annually, and his being
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directly responsible - from beginning to end, for producing the financial statements for
each of these units (id.; see also, id., 0:02:50), established the following facts:
A. Bartus has been in the ambulance transportation industry a little
over 22 years, beginning with general operation duties, communication and
dispatch roles, as well as overseeing fleet maintenance. After obtaining his
bachelor degree in accounting, he moved into the business-side of operations in
1994, and started producing financial statements and doing financial analyses.
He then moved into upper level financial management, and performed executive
level operation duties associated with acquisitions, enhancing his business
knowledge. He then moved back into the financial-side of operations, at the
executive level. Id., 00:14:00.
B. Bartus is involved on a day-to-day basis with overseeing the
financial operations of AMR’s business units, including the month-end closing
process and balance sheets. This includes revenue projections for contract
performance, monthly and quarterly forecasting, managing capital expenditure
calculations and annual budgets, and preparing pro forma projections for new
contracts and responses to requests for production. Id., 0:02:13.
C. The approximate distribution of 911 generated versus IFT
transports in his area is approximately 50/50. It also covers every different kind
of community from very rural (such as River Medical), to the highest urban
concentrations, such as Las Vegas. Id., 0:03:30.
D. Bartus is familiar with the preparation of Arizona’s ARCRs, both
actual and pro forma, by virtue of the River Medical operation as well as AMR’s
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applications for new operations and transfers, including Life Line. He reviews all
numbers for River Medical and Life Line, ensures they are compliant with
generally accepted accounting principles (GAAP), and is otherwise directly
involved from beginning to end in preparing them. Id., 0:04:40.
E. Bartus is familiar with Arizona’s regulatory model, which while fairly
unique is similar to the financial reporting required by other states’ rules and
regulations, and to certain contract compliance requirements. Id., 0:06:35.
F. Bartus’ preparation of these various financial statements, and
Arizona’s ARCRs, does require familiarity with the different calculations third
party payors make for reimbursements. This is important because the key
driving factor for success of an ambulance transportation entity, including
making pro forma calculations (such as an estimated first year ARCR) and
bidding on contracts or budgeting, is appropriately estimating revenue. This
includes the rates that third party payors will pay and a collection risk analysis,
as well as co-payment risk analysis and the risk of transporting patients who
simply cannot pay. Id., 0:08:43.
G. Bartus is familiar with the payor mix an ambulance transportation
company will work with, including analyzing trends and changes. The mix
involves four categories of parties who will pay for ambulance transportation
services:
(1) Medicare - the largest group of users;
(2) Medicaid – the second largest;
(3) Third party insurance companies; and
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(4) The uninsured who are self-pay (a group carrying the
highest risk of bad debt).
With regard to the last group, an ambulance transportation company
must transport regardless of a person’s financial status. Id., 00:11:05.
H. Arizona’s Medicaid reimbursement has recently changed, for the
better. It is administered by the AHCCCS program, and recently went from
68.59% of the gross charges to 74%. Id., 0:13:05.
I. River Medical, Inc. is wholly owned by AMR. Id., 00:16:35.
J. In connection with the GVFD Application, Bartus applied his
knowledge and experience to analyze GVFD’s financial model, preparing
Exhibits RMI 41(A), (B) & (C). Id., 00:16:55.
K. In doing this, his goal was to review the applicable data and test
GVFD’s calculations for reasonableness. Id., 00:18:25.
L. This review includes the fact that the fundamental basis of any
financial model must be revenue. Id., 00:20:00.
M. His analysis was not done using 2012 standards, due to changes
in relevant financial considerations, such as the Affordable Care Act. Id.,
00:21:07.
N. To do this, he looked at the payor mix and analyzed how the
GVFD payor mix has changed from 2012 to 2014 by looking at the known 2012
ninety days sample period for GVFD, the known River Medical 2012 payor mix
for that same ninety day period, calculating the difference, and looked at the
known payor mix for 2014, to then calculate the best estimate for current GVFD
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area payor mix. He updated Medicare rates to those applicable in 2014. He
utilized current Medicare reimbursement rates and utilized historic River Medical
collection rates, which includes the risk associated with co-payments and the
small category of self-payors (see, RMI Ex. 41(A), first page). Id., 0:23:13;.
O. RMI Ex. 41(C) contains the detailed math behind all of his
modeling. He created 24 different financial scenarios for his analysis. The first
12 leave GVFD’s proposed rates the same, assuming GVFD’s cost/expense
calculations are correct, and then applied the variables (changing Medicare
rates, AHCCCS rates, co-payor risks, etc.), to determine what the true taxpayer
burden would be. The second 12 financial models looked at the same variables
but kept the taxpayer burden (subsidy) the same and calculated what the rates
would need to be to achieve that. These 24 models also used two different
projected billable transport numbers. The first is the 1,100 transports, which
GVFD’s financial model is based upon. Because Bartus is confident that the
real billable transport number would be 800, that number was also used. The
800 number is based upon River Medical’s data and information elicited during
the hearing (see, RMI Ex. 41(A), pp. 1 and 2). Id., 0:26:00.
P. For both the “do not change GVFD’s proposed rates” and “keep
the same taxpayer burden,” Bartus looked at the worst case/best case scenario
for each (with regard to AHCCCS reimbursement changes). Id., 0:31:00.
Q. The basis that Bartus started with was GVFD’s first year, pro
forma, ARCR (GVFD Ex. 154). He also utilized GVFD’s expense calculations
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(GVFD Ex. 124), then applying the existing 2014 payor mix, as best calculated
for GVFD. Id.,0:33:50.
R. River Medical Ex. 41(B) details Bartus’ financial modeling and
conclusions. Due to the passage of time, GVFD’s revenue model was out of
date with respect to Medicare rates, Medicaid (AHCCCS) rates and payor mix.
It erroneously assumed a 100% collection of Medicare with no provision for the
2% sequestration reduction or co-pay collection rates. It also had no provision
for possible denial of claims by AHCCCS, a higher than industry normal
collection rate for self-pay and (in Bartus’ opinion) was overly optimistic about
the number of billable transports [see, RMI Ex. 41(B)]. Id., 00:37:30.
S. For example, GVFD used a 60% collection rate for self-pay
(uninsured population). River Medical’s experience is that number should be
7.7%, a number consistent with national trends. Id., 00:43:15.
T. The second page of RMI Ex. 41(B) shows how the payor mix was
calculated, using known data for River Medical for the GVFD selected 90 day
period in 2012 as compared to known River Medical 2014 data through August
5th. The third page shows GVFD’s known data for the same 90 day period in
2012, he applied the same percentage change that River Medical, as a whole,
experienced as between that 90 day period in 2012 to 2014, thereby calculating
the estimated adjusted payor mix totals for GVFD in 2014 [see, RMI Ex. 41(B),
second and third pages]. Id., 00:49:08;.
U. The fourth page of 41(B) is historical closed claim data. Bartus
looked at collections over a two year period, to see the true experience, and
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then compared to GVFD’s collection assumptions to test for reasonableness
using all trips billed for the first quarter of 2014 (by River Medical), which quarter
was entirely closed as of the time of hearing. This allowed him to determine
River Medical’s current collection rates and then apply the change to known
GVFD 2012 rates [see, RMI Ex. 41(B), starting at fourth page]. Id., 0:52:30.
V. The final part of his calculations simply involved Bartus recreating
GVFD’s expense calculations (GFVD Ex. 124) in a spreadsheet [the fifth and
sixth pages of RMI Ex. 41(B)]. Id., 0:56:45.
W. Then, using GVFD’s pro forma ARCR numbers, accepting GVFD’s
proposed rates and charges, he created 12 scenarios applying the three
possible AHCCCS rates – pre October 1, 2014 rate of 68.59%; the October 1,
2014 existing rate of 74%; and the expected October 1, 2015 rate of 80%. He
applied each of these three, first using the overall River Medical known 2014
payor mix (through August 2014) and utilizing 1,100 transports. This is line
items A through C. He did the same, adjusting only the payor mix to be the best
estimated GVFD specific payor mix. These are line items D through F. He next
did the same two sets of calculations, but using 800 transports (line items G
through I and J through L, respectively). See, RMI Ex. 41(A), p. 1; RMI Ex.
41(B), seventh page, Bates Numbered 873; see also, id., 1:00:20.
X. He determined that line item K was the most likely scenario based
upon known information. It contains the most current payor mix specific to
GVFD’s area, the current AHCCCS reimbursement rate, and the best estimate
for billable transports. Settlements include the impact of Medicare sequestration
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and the higher Medicare rates. He also included the “super rural” enhancement
to Medicare, noting that this enhancement is at risk every year (dependent upon
Congress). Id., 1:02:45. See also, 1:17:35.
Y. Based upon this, he concluded that if GVFD’s proposed rates are
accepted, their revenue projections are short of true by approximately $341,567
(they will receive this much less in revenue than what was projected). This
figure is found at line item K in the boxed out area under the heading $$
Taxpayer Change [see also, RMI Ex. 41(B) at Bates 0873]. Id., 1:07:25.
Z. As such the true taxpayer burden (the deficit between revenue and
expenses) is not the $894,819 assumed by GVFD, but instead is $1,236,387.
This is found at line K under “Taxpayer Burden $$.” Id., 1:09:00.
AA. At RMI Ex. 41(B), Bates No. 0874, the illustration of Schedule K,
and all the math involved, immediately follows the summary of Bartus’ financial
modeling for all 24 different calculations.
BB. Bartus’ financial modeling then looked at 12 different scenarios
applying the same basic principles and calculations as the first 12, but leaving
the taxpayer burden the same, in order to calculate what GVFD’s rates would
need to be in order to keep the same taxpayer burden. As with the first 12, his
assumptions include GVFD running three ambulances, 24 hours a day, 7 days a
week. Id., 01:12:10.
CC. There, line item W corresponds to line item K. It applies current
payor mix specific to the GVFD area, current AHCCCS reimbursement rates, the
impact of sequestration and assumes 800 billable transports. Based upon this,
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GVFD’s rates would have to be a little more than double what they have
proposed in order to maintain the same taxpayer burden (subsidy). These
calculations do not necessarily follow a straight line as increasing rates will not
change Medicare reimbursement. Medicare looks at its fee schedule and allows
80% of that minus the 2% sequestration (the 2% sequestration is 2% of the
80%, not of the whole). The member then pays 20% of the Medicare fee
schedule. The Medicare reimbursement does not move with increased rates.
AHCCCS is currently responsive to rate changes but if everyone raises their
rates a lot, AHCCCS will respond, as it has a set fund. Third party HMOs are
also starting to become more savvy in this regard, meaning higher rates do not
necessarily result in proportionate reimbursement increases. Id., 1:14:07; see
also, id., 1:24:05.
DD. The RMI Ex. 41(B) illustrations of Schedule K and W are
essentially the “playbook” for an ambulance operation company to calculate its
revenue. Id., 1:23:36.
EE. The detail for Schedule W, the rate increase required to maintain
GVFD’s projected taxpayer subsidy of $894,819, is found at RMI Ex. 41(B),
Bates No. 0874, and includes calculations of what happens to cash when rates
are raised. One risk factor Bartus skipped here, which would further decrease
revenue, is “price elasticity” (line item K). Private insurance payors will pay less
if they believe rates have been raised to cost shift. Id., 1:24:25.
FF. RMI Ex. 41(B) concludes (final two pages) with graphs that
correspond to the 24 different scenarios Bartus ran in his financial modeling,
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with the first corresponding to line items A through L (where rates are kept the
same and the required taxpayer subsidy changes) and the second keeping the
taxpayer subsidy the same.
GG. Bartus’ ultimate conclusion is that no matter which model is run,
and giving GVFD all the benefit of the doubt (increased Medicare and Medicaid
reimbursements, etc.), there will be a deficiency somewhere. Scenarios K and
W are the most likely and he believes there is a high risk of GVFD financial
instability and failure [see, RMI Ex. 41(B), p. 1]. Id., 1:31:45.
HH. Bartus also spoke to the general financial impact GVFD’s
proposed business model would cause to River Medical. GVFD calculates that
it will take 100% of the billable transports in its proposed service area.
However, River Medical’s CON will still require it to cover that area, and meet its
response times. As such, River Medical would need to keep an ambulance
available for the GVFD area, in case the “backup” service that GVFD spoke of is
required, and to cover the surrounding rural area. It costs approximately
$500,000 to staff one ambulance. At best, the revenue generated would be
about $210,000, meaning there would be a negative burden associated with this
ambulance of approximately $290,000. While River Medical could reduce units
in the area, for approximately 800 transports per year, there is no way to do a
pro rata billing staff or other large organizational cost reduction, in the way that
River Medical could do if it lost, say, 20,000 transports per year. Id., 1:34:15;
see also, 2:52:18 and 3:04:55.
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II. For any ambulance company, the biggest cost is putting an
ambulance on the road, which is approximately $500,000. Id., 1:39:55.
JJ. The “donut hole” that the GVFD service area represents is not only
surrounded by the rural areas adjacent to that part of River Medical’s service
area, it is also impacted by the Lake Mohave Ranchos and Bullhead City Fire
District service areas, to which River Medical provides mutual aid, as well as the
Skywalk area on the Indian Reservation. There is no significant overlap
between these service areas and any other provider, they are pretty much
standing alone. Id., 2:56:36.
KK. Having to continue to cover this “donut hole” in the service area,
as well as the surrounding sparsely populated area, could possibly cause River
Medical to have to apply for a rate increase somewhere between 5% and 6%
(this is an option it would have to consider), or a possible modification of its
CON service area. Id., 1:35:00; see also, 2:53:05.
LL. Bartus also spoke briefly to AMR and its parent’s financial stability.
AMR is wholly owned by Envision Health Care (“EVHC”). All debt is held by that
parent, which debt is significantly less than when the company went public.
EVHC accelerated payment on its debt, which allowed it to restructure its
remaining debt at lower rates. It has had no problem with its ability to pay this
debt. Id., 1:41:55; see also, 2:58:30.
MM. Bartus was asked to discuss the fact that GVFD considers there to
be no true financial impact through its using the 24 firefighters it is already
paying for, only adding 4 additional employees to the “true” ambulance transport
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expenses. He characterized this proposal as “unrealistic” and “unreasonable”
and said that he could not follow that math. Id., 2:17:22.
NN. He has a “fundamental problem” accepting this proposition. If
GVFD uses existing resources to staff its 24 an hour a day, 7 day a week, three
ambulance operation, it will not have sufficient employees to provide fire
suppression services. Or, if it has a motor vehicle accident that requires a fire
truck and two ambulances to respond, there will be no staff for the third
ambulance. Id., 2:59:30.
OO. Bartus “fundamentally” disagrees with GVFD’s hypothetical
proposition that the only labor expense that should be considered in connection
with the ambulance revenue projections is four full-time employees ($360,000).
Id., 2:22:50; 2:24:49.
29. Thomas O’Donahue (second witness, Thursday, 10/30/14 p.m.,
beginning at 3:06:35; direct exam continuing Friday, 10/31/14 a.m., beginning at
0:0:52; rebuttal Wednesday, 11/05/14 a.m., beginning at 1:06:2), Chief of GVFD:
A. Chief O’Donahue wants the GVFD to start providing ambulance
transport services because he thinks it is in the best interests of the community.
He believes GVFD can provide sufficient ambulances to cover those calls, and
the community (through survey and by their comments) would like that; they are
unified in their desire. He believes this would not be a burden on the taxpayers
and would give GVFD “local control.” 10/30/14 p.m., beginning at 03:06:35.
B. O’Donahue’s professional experience is primarily in the area of fire
services, not ambulance transportation services. He described minimal
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experience in operating a fire-based ambulance service and neither he nor his
Résumé detailed anything in the way of clinical expertise. He has no clinical
training or active certifications (see, GVFD Ex. 69). Id., 3:07:55.
C. O’Donahue believes his directive from the GVFD Board was to be
a “change agent” (former Chief Hewitt was also so charged). Id., 3:12:40.
D. Current GVFD Fire Station No. 12 is on the far west side of the
district, Station No. 11 is on the east side, and Station No. 13 is to the south,
close to the I-40 corridor. Id., 3:20:11; GVFD Ex. 163.
E. Tax revenues are the district’s main funding source. Id., 3:34:40.
F. For the fiscal year ending June 30, 2011, the district had over $3.8
million in its general fund. By the end of that year, he was the Chief. A
significant portion of this money was spent on a “brand new” fire station and
training center and equipment purchases, reducing that general fund to
approximately $1.4 million and change. Id., 3:36:50; 3:41:50.
G. Over the last ten years, GVFD has experienced a significant
decline in property values (see, RMI Ex. 27, showing $161,485,514 in 2009 now
reduced to $60,574,181), which resulted in less tax revenue. This caused he
and Chief Hewitt to look for alternative revenue sources. Id., 3:42:30. Over the
last two years, there was also an increase in the tax levy, from $2.50 to $2.90
per $1,000 value of real property (the cap is $3.25). Id., 3:43:45.
H. GVFD approached their base hospital about putting together a
“community para-medicine program,” but the hospital declined, so GVFD is
“doing its own thing,” which was described as a paramedic who treated a patient
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calling that patient subsequently to find how they are doing and to see if that
patient wants then to come back out (presumably to the patient’s house) to do
things such as check medication, do blood pressure checks, answer questions
about medications, etc. Id., 3:48:00. After direct examination, when questioned
by counsel for ADHS/BEMSTS, it was established that doing this without Dr.
Ward’s supervision would be beyond the allowed paramedic scope of practice.
10/31/14 a.m., beginning at 3:05:10.
I. The Chief offered letters of support from members of the
community (GVFD Ex. 117), which letters merely stated support, as opposed to
establishing any substandard performance by River Medical or current deficits in
or problems with the ambulance transportation services provided by River
Medical (GVFD Ex. 117). 10/30/14 p.m., beginning at 3:52:15.
J. The GVFD provides many important fire, hazard and public safety
services including fire suppression, hazardous material responses (such as fuel
spills and toxic material responses), technical rescues, responses to bee or
snake incidents, and EMS first response. Id., 3:54:10.
K. GVFD does approximately 12 structure fires a year. Id., 3:54:10.
L. On average, the GVFD goes out to approximately five to six calls a
day, but has other duties including its employees studying, training, exercising,
and sleeping (they work 48 hour shifts). Id., 4:04:31.
M. The most time intensive responses are fire incidents, especially
structure fires, which can easily last an hour or two, or even four to five hours.
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Hazardous calls also take a long time as slow movement is required. 10/31/14
a.m., beginning at 0:05:43.
N. GVFD employs Captain Arnold as its own trainer of paramedics
and EMTs. His qualifications were described by the Chief as Arnold’s prior flight
medic experience, the fact that he was a Marine and swat trained, and his “long
history of teaching.” He has been with the organization for approximately four
years. Id., 0:11:06.
O. Arnold’s role in the organization was described as that of attending
meetings (local and regional EMS), teaching, and if there were “new advances,”
he would go to classes and then pass the information along. Id., 0:12:30.
P. O’Donahue did not detail any management or oversight
responsibilities Arnold might have in the event of GVFD receiving a CON (id.).
Arnold was not called as a witness to establish any facts about his clinical or
management training, education or experience. No facts were presented to
show what he did prior to joining GVFD. GVFD did not admit any exhibits
detailing Arnold’s background or experience, and GVFD’s Application also
contains no such information.
Q. GVFD employs 13 paramedics and approximately 10 EMTs; it
works on a minimum staffing of 7 employees. Station Nos. 12 (west side) and
13 (south) each have a minimum of 2 people, a firefighter and a paramedic.
Having less than 2 at either of these stations “would shut down the station.” Id.,
0:13:30. Main station (No. 11) is staffed with a minimum of 3 or 4. There is also
a daytime Captain paramedic at Station No. 11, between 8:00 a.m. and 5:00
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p.m. who can be held over. Id., 0:14:10 (see also, 10/30/14, beginning at
4:05:40).
R. O’Donahue’s detail regarding GVFD’s four volunteers was limited.
He states they are training to become full-time employees, he “believes” all are
EMT certified. If necessary, they could be looked to in order to staff a three
person response unit. Id., 0:14:40; see also, id., 2:38:20 (only 4 volunteers).
S. O’Donahue stated that GVFD does “move up” its units. If primary
Station No. 11 had a car fire, it would take a crew of three to respond. If on the
heels of that, Station No. 12 had to respond to a medical incident (meaning both
Station Nos. 11 and 12 would be empty of all their emergency response
employees), they would “move up” the employees from their slowest station
(Station No. 13) to No. 11. Id., 0:19:56. It must be noted that even with that
“move up,” under the circumstances described, this would leave only one fire
station staffed with 2 people for the whole district.
T. In discussing the fact that GVFD utilizes a separate dispatch from
River Medical, O’Donahue articulated his concern about “potential issues”
arising due to the dual systems, the perceived “opportunity for error,” but
identified no actual negative consequences or systemic problems. Id., 0:25:00.
U. GVFD’s proposed ambulance transport service model involves it
bumping up its current 7 personnel minimum staffing to just a minimum staffing
of 8, adding 4 new firefighter EMTs (not adding any new paramedics) and
purchasing 2 additional ambulances to supplement the 2 already owned. Id.,
0:40:00.
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V. Two of those ambulances will be posted at Station No. 11, one at
Station No. 13, and Station No. 12 (east side) will be used exclusively for fire. A
fourth ambulance will be stored in the “shop” behind Station No. 12. Id.,
0:41:20.
W. Assistant Chief Jack Yaeger will be in charge of ambulance
operations. His professional background (GVFD Ex. 123) states no clinical or
ambulance operation education, training or experience – it only details fire
training and experience. Jack Yaeger was also not called to testify as a witness.
However, over River Medical’s objection, Chief O’Donahue stated Yaeger’s
qualifications has having an “extensive background” in fire service, as him being
“someone who had lots of experience” in EMS and ambulance background with
the Mohave Valley Fire District. No detail was provided. Id., 0:43:10.
X. According to GVFD’s Application, GVFD stated its intent to hire a
new EMS coordinator and to use Ted Martin to run ambulance operations. See,
Osborn testimony, supra.
Y. O’Donahue also testified to the possibility of the district doing “call
backs” of off-duty employees when there are large incidents that would strain
resources. However, he did not detail how this would impact employees who
had just gotten off a 48 hour shift, how long the transportation times for these
employees might be (especially the approximately 75% of firefighters who live
outside of the GVFD area), and how this might delay emergency responses,
other than to acknowledge there was a “slight delay” in a first responder EMS
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call received at the time of a structure fire involving a Board member’s house.
Id., 0:46:20; see also, 00:51:40.
Z. He acknowledges that running ambulance transports will take
more time than simply being a first responder. Id., 0:56:10.
AA. To establish attention to ADHS/BEMSTS quality assurance
programs, O’Donahue testified to what he called an “informal” review of certain
medical incidents, by GVFD Captains, looking for improvement. Id., 0:59:10.
BB. He initially stated that GVFD is a participating Premier Agency, but
then acknowledged they are currently only a “participating Agency” and moving
forward to become a Premier Agency. Id., 1:01:30; see also, GVFD Ex. 23. He
stated they follow written protocols (generated by their Medical Director, Dr.
Ward) for time sensitive medical conditions and that Dr. Ward does run reviews,
inviting all participants to review these incidents. Id., 1:04:50.
CC. With regard to attendance at state and regional EMS meetings, he
testified that GVFD “tries to participate” in the western (regional) meetings,
stating that over the last couple of years they attended 6 out of 11. Id., 1:04:10.
DD. Recently, GVFD had an issue with not making timely payment of
its payroll taxes, which resulted in IRS fines. They found out what they thought
was the problem and gave clear instructions to correct this, but it happened
again, and they were fined again. The person responsible for these errors was
Nicole Guerrero, who was GVFD’s Administrative Manager. They removed her
from that position. Id., 1:06:55.
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EE. Nicole Guerrero has made “multiple” allegations against GVFD,
including sexual harassment and “hostile work environment.” Her allegations
are still under investigation. Id., 1:09:38.
FF. O’Donahue admitted wearing an official GVFD “certified
paramedic” T-shirt to the scene of a structure fire where he was photographing
talking to a taxpayer (he is not so certified). Id., 1:16:24. The photo was posted
to GVFD’s website and removed after a complaint. Id., 2:24:35.
GG. O’Donahue acknowledged at least one incident of unprofessional
conduct by one of his firefighters, while on duty; he is not contending all of his
employees act perfectly at all times. Id., 1:19:30. He likewise acknowledged
that during his tenure there has been at least incident that he can recall where
either his dispatching entity gave GVFD the wrong address, or GVFD itself did
not know the correct address. Id., 1:58:44.
HH. If GVFD receives a CON, and begins billing for ambulance
transports, O’Donahue does not know who will do its billing. There are different
options to consider. Id., 1:26:15. GVFD will utilize a Kingman regional dispatch,
which he characterized as a “cooperative for fire users.” He provided no detail
regarding whether this entity dispatches (currently) for any ambulance
transports, what knowledge or expertise it has and provided no information
regarding how that dispatch or relationship will function. Id., 1:26:57.
II. GVFD has no plans to remodel Station No. 12 to increase
available staff housing or add an ambulance bay. Instead, GVFD’s plan is to not
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have any ambulance run out of Station No. 12 (even though it is the second
busiest station). Id., 1:30:00.
JJ. If a River Medical ambulance is located within GVFD and needs to
go to the Bullhead City area, it would not be most efficient to head east and
pickup Highway 68. Instead, the River Medical unit would head straight through
the GVFD area, west to the Bullhead City service area. Id., 1:31:50.
KK. GVFD firefighters exercise 90 minutes a day due to the physical
demands of firefighting, and for employee health. Id., 1:31:15.
LL. In addition to their regular firefighter duties, O’Donahue uses his
full-time employees, and volunteers, to provide the wild land fire responses
GVFD contracts for in order to gain revenue. Id., 1:33:18.
MM. GVFD paramedics and EMTs work 48 hour shifts, which includes
the requirement of time to sleep. Otherwise, they would be putting patients,
GVFD employees and the public at risk. Id., 1:45:00.
NN. GVFD has received criticism from at least a couple of the district
residents over utilizing a tax rate that allowed GVFD to acquire the general fund
surpluses seen in prior years. Id., 1:34:05. In general, the philosophy and
parameters of a fire district, in a perfect world, is that of taxing to meet its budget
only, or the taxes are too high. Id., 1:35:25.
OO. O’Donahue’s discussion of his “community paramedicine” program
demonstrated his lack of familiarity with the limitations Arizona places on
paramedics – his program does not recognize those paramedics can only
operate under their Medical Director’s supervision and license. For, although
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GVFD’s base hospital turned down his request for its participation in a
community paramedicine program, GVFD is “doing it anyways” (spending
between 20 and 30 minutes, on average, for each contact). Id., 1:38:25. The
discussions the paramedics might have with their prior EMS first response
clients could include questions regarding medication. Id., 1:40:20. When asked
by counsel for ADHS/BEMSTS whether this would be under the medical
direction of Dr. Ward (GVFD’s Medical Director), O’Donahue responded in the
negative. While carefully stating the paramedics would only answer questions
within their certificated expertise, he did not back off of his position that this
could involve medication and is apparently allowing his paramedics to do this
without the supervision of either GVFD’s Medical Director (Dr. Ward) or base
hospital. Id., 3:05:10.
PP. O’Donahue agrees that River Medical has more experience than
GVFD does in the area of doing ambulance transports. Id., 1:42:14.
QQ. In general, if GVFD experiences a structure fire, its protocol is to
call out three engines. O’Donahue agrees this involves a certain cost of
readiness (to have those staffed and available). If a GVFD resident’s home
catches on fire, they will expect GVFD to show up. Id., 1:42:59.
RR. Whether GVFD will continue to act as a first responder in the event
it receives a CON, depends upon the incident. Id., 1:48:00. If it was a “minor
medical call,” which O’Donahue characterized as including a broken arm, only
an ambulance (two employees) would be dispatched. The determination of
whether or not an EMS first response was required will be made by the
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dispatcher, not GVFD. Id., 1:49:07. If only an ambulance responds, there will
be just two medical personnel on scene. Currently, every call for an ambulance
transport in GVFD receives at least four medical personnel on scene, at least
two paramedics and two EMTs. Id., 1:51:30.
SS. O’Donahue acknowledged that once a paramedic/EMT arrives on
the scene, a call can end up looking differently from what the dispatch indicated.
Likewise, he acknowledged that what appears to be a “minor medical” calls can
transition into a major medical call, on scene. Id., 1:49:07.
TT. O’Donahue agreed that if by looking at the history for a specific
area, one sees all calls for ambulance transports have been responded to within
the timeframe established by the governing agency as reasonable and
appropriate, and there has been no history of substandard performance issues
and a community decides that despite this, it wants to double the number of
ambulances normally available, this doubling would be a “luxury.” Id., 1:52:25.
UU. As examples for how long GVFD “hazard” calls might take, a fuel
leak spill on Highway 68 took approximately 30 minutes and the swift water
rescue he testified to during direct examination required GVFD to be engaged
approximately 2-1/2 hours, which incident involved all GVFD units (and all staff).
Id., 2:00:00. If at the time of that swift water rescue, GVFD had a CON and
there was one or even two calls requiring ambulances, GVFD would possibly
have to “request mutual aid” from River Medical. Id., 2:02:20.
VV. O’Donahue also demonstrated confusion regarding who could
request ambulance transportation services via a “mutual aid” request. He
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started out stating that within the last year, GVFD had requested ambulance
service via mutual aid from Bullhead City once (but was unable to give the
month, situation, or even any better location than “maybe Highway 68,” id.,
2:04:58). However, when asked whether he was stating that a fire district not
holding a CON could request an out of CON service area ambulance response),
he backtracked. Id., 2:05:50.
WW. O’Donahue testified he would anticipate a mutual aid agreement
with River Medical (even though River Medical is already certificated in GVFD’s
proposed service area). Id., 2:06:50.
XX. O’Donahue admitted there was no information indicating that
between January 2009 and July 2014 GVFD did any “hazardous responses”
that also involved a medical situation requiring an ambulance transportation
response. Id., 2:08:25.
YY. Training like that done for PaxAir takes approximately one hour on
the scene and involves at least two firefighters, possibly more. Id., 2:13:30.
ZZ. To cover employees who are on vacation or sick, GVFD only has
one “floater.” Otherwise, it has to rely upon overtime. Id., 2:30:25.
AAA. O'Donahue acknowledged using off duty personnel for training, or
if they found themselves “thin,” would involve payment of overtime, but was
unsure whether overtime payments were calculated in GVFD’s first year ARCR.
Id., 2:14:20.
BBB. While GVFD’s Station No. 12 is the second busiest, GVFD does
not plan on having a fully staffed ambulance available there. Id., 2:16:00.
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O’Donahue disagreed with GVFD’s mechanic, Mr. Sutherland, that the
intentions for GVFD’s fourth ambulance is to use it for training and
maintenance/repair. Id., 2:16:30. When asked what resources GVFD would
have in order to fulfill its three full-time ambulances schedule, if two of GVFD’s
ambulances were “down” (for maintenance or repairs), his response was that
they would have to “repair one quickly.” When asked if he might instead ask
River Medical for help, he slowly and reluctantly said that he imagined “that
could be an option.” Id., 2:17:35.
CCC. If a structure fire were to occur while an ambulance was already
out on a call, and then GVFD received a second call requiring at least two
ambulances, O’Donahue would look to a “mutual aid.” Id., 2:19:10.
DDD. With regard to the State Premier Agency program, O’Donahue
was not aware that GVFD could be filing its patient data manually, via the
website (instead of waiting for the computer issues he testified were delaying full
participation). He is “not directly managing that program.” Id., 2:22:20.
EEE. O’Donahue also did not know the amount of funds involved in
GVFD’s recent IRS problems. Whatever that amount of money was, it had been
collected from the employees and was left sitting in GVFD’s bank accounts,
rather than being transferred to the IRS. The person responsible for this error,
Nicole Guerrero, is the same person who calculated GVFD’s “zero/1” data (River
Medical ambulances available in district). Id., 2:32:20.
FFF. With regard to Firefighter DeMaio (who wrote an email to the
Director opposing GVFD receiving a CON – EMS Ex. 20), O’Donahue
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acknowledged that the discipline DeMaio was unhappy with and that O'Donahue
testified to during his direct examination occurred after DeMaio took a very
public stance against the CON pursuit. Id., 2:28:15.
GGG. The Griffith representative (Mike Hartsig) erred when he testified
that River Medical did not respond to a hazardous material incident at Griffith.
Instead, a River Medical supervisor, Chuck Waalkens, was personally at the
scene to make sure River Medical employees who were also there, on standby
(in case an ambulance was needed), were safe. Id., 2:28:50.
HHH. It is GVFD’s intention to cover 100% of all 911 generated
ambulance transportation calls in its proposed service area. O’Donahue will
instruct Kingman dispatch to send GVFD all ambulance transport calls. If GVFD
cannot handle a call, O’Donahue intends to be the one who will decide who is
then called “for mutual aid.” Id., 2:32:05. ADHS/BEMSTS clarified with
O’Donahue that the decision about contacting mutual aid partners would in great
part be cut short by the fact that the 911 dispatcher, if it knows all GVFD units
are unavailable, would then look to River Medical. Id., 3:15:39.
III. It takes more time and involves more duties to do ambulance
transportations than being the EMS first responder. Id., 2:34:30.
JJJ. GVFD has no plans to hire any additional mechanical service
employees. Id., 2:35:33.
KKK. In addition to using prison labor as an assistant to GVFD’s one
mechanic, prison labor is also used other things, including maintenance,
construction, cleaning, and washing and waxing district vehicles. Id., 2:35:33.
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O’Donahue has not explored whether there are any associated
Medicare/Medicaid implications. Id., 2:37:33.
LLL. The square mileage of the existing GVFD district, not including the
roads only addition, is approximately 177 square miles. The additional (showing
as light green on GVFD Ex. 118) area outside of the fire district that GVFD
proposes to add will more than double that, adding approximately 253 additional
square miles. Id., 2:38:50.
MMM. The “handles” that GVFD tagged onto its proposed service area
(following the highways north and south of the district), and the portion of I-40
wholly contained within the currently out-of-district but proposed in-district
service area, do contain a number of businesses including Griffith Energy,
NuCor Steel, and other clusters of businesses. Once you get beyond nearby
Grasshopper Junction (going north) and Yucca (going south), there is not much
in the way of businesses or other structures, it is instead “pretty sparse”
highway, which GVFD has not included in its proposed service area, and which
River Medical will still be required to cover. Id., 2:45:50.
NNN. River Medical offers a subscription service that covers everyone
in the household under the age of 21. GVFD will not offer this. Id., 2:40:40.
OOO. Other than a guard accompanying the ambulance on the
transport, O’Donahue is not familiar with any policies or procedures that would
be unique to the supplies associated with providing ambulance transportation
services to the local prison. Id., 2:41:32.
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PPP. Currently GVFD is not always the first to arrive on scene of an
emergency medical services call, even in its status as the EMS first responder.
River Medical arrives before GVFD approximately 20% of the time. Id., 2:43:00.
QQQ. GVFD has publicly stated it does not intend to pursue collections
for ambulance transportation services that are not covered by third party payors.
O’Donahue does not know if this applies to non-district residents or not. Id.,
2:53:30.
RRR. GVFD’s tax base has been declining ever since 2009, when the
net assessed value was $161,485,514. Within two years, it was just under
$85,000,000 and by 2014, it was $60,574,181 (RMI Ex. 27). Id., 2:56:40.
SSS. O’Donahue is unaware of any medical literature stating that
simply increasing ambulance response times will improve all patient outcomes.
Id., 3:00:35.
TTT. Other than being notified by dispatch as to whether or not a
patient requiring ambulance transport is suspected of having the EBOLA virus
and the GVFD staff then protecting themselves with proper respiratory covers,
O’Donahue could not speak to any current GVFD EBOLA identification
(patients) strategies or protocols used to notify healthcare providers of potential
patient problems. All he could say was that GVFD was “currently working with
ADHS” about how to better prepare. He was unable to identify any other
infectious disease protocols GVFD is working on. And when asked about how
employees were being trained with regard to “donning and doffing” protocols
(understanding that this was what was involved in the recent Texas EBOLA
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contamination issue), O’Donahue’s response was that he is “not getting involved
in direct training of his personnel.” Id., 3:01:14.
UUU. When asked how GVFD staff are currently benchmarking any
cardiac arrest metrics, O’Donahue was unable to respond, stating that question
would needed to be asked of Captain Arnold (who was not called by GVFD as a
witness). Id., 3:03:10. GVFD is not participating in the CARES program (see,
infra testimony of Dr. Racht for discussion of CARES). Id., 3:03:38.
VVV. O’Donahue holds no college degree. He has never been certified
as an EMT or paramedic in Arizona. He holds no current EMT or paramedic
certification from any other state. He is not a medical doctor. Id., 3:04:20.
Likewise, his CV (GVFD Ex. 69) contains much in the way of fire education and
training, but nothing in the way of medical/clinical classes or training.
WWW. When asked by ADHS/BEMSTS about GVFD’s participation in
the Premier Agency Provider program, O’Donahue stated GVFD’s intent to meet
all of that programs requirements. He acknowledged this includes submission
of electronic patient care records. He stated the issue there is with GVFD’s
internet connectivity, which he “thinks” has been taken care of. However, GVFD
has not yet acquired the required software (EPCR software). He was unable to
state how long this will take. Id., 3:08:00.
XXX. When also asked by ADHS/BEMSTS regarding attendance at
Regional EMS Council meetings, he stated that (former employee) Ted Martin
was attending, that new hire Yaeger has been charged with attendance, and
then added that he had personally attended the recent Arizona Ambulance
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Association meeting (without explaining how that Association corresponds to the
Regional EMS Council). Id., 3:09:00.
YYY. When asked by ADHS/BEMSTS to explain what the needs are in
GVFD, that might justify GVFD going into the ambulance business, O’Donahue
spoke in general terms regarding the desire for ambulances to be located within
the district (GVFD) and did not identify any specific facts showing a shortage of
ambulances or substandard service. His testimony was that GVFD does not
“have ambulances in our community” to the level that they think they really
should, River Medical only arrives before the first responders 20% of the time,
he thinks this is an unacceptable gap in coverage for the community. He added
his “worry” when he sees one River Medical ambulance sitting at a gas station
for hours (worry about employee fatigue and no other ambulances being “in the
community” for a second call). He believes when there is a second River
Medical ambulance in community, it “often is pulled out for long distance
transfers. However, none of this involved a description of any statistics or
incidents showing any River Medical failure to provide a timely and appropriate
ambulance transport response. Id., 3:10:23. He elaborated on his desire to
personally have control of ambulance transports. He wants local accountability,
which he believes is the equivalent of a “more reliable service.” Id., 3:12:14.
ZZZ. BEMSTS requested a GVFD Board resolution acknowledging that
according to BEMSTS’ analysis, GVFD’s ARCR shows an ambulance service
with costs that exceed revenue that will not be profitable. Id., 3:17:40.
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AAAA. On rebuttal (Wednesday, 11/05/14 a.m., beginning at 1:06:20),
O’Donahue acknowledged that there are EMS calls where it is desirable to have
four responders on the scene of an incident. Id., 1:33:40.
BBBB. Brad Shelton was just elected to serve on his local fire district
board. Id., 1:37:31.
CCCC. With regard to the GVFD Board, one of the newly elected Board
members is a vocal opponent to the CON process. Id., 1:37:44.
DDDD. GVFD’s Medical Director, Dr. Ward, has not agreed to oversee
a community paramedicine program, and O’Donahue agrees that the
paramedics must have Ward overseeing their paramedic duties. Id., 1:40:20.
EEEE. With regard to the operations he ran in Washington State, the
one relying on volunteers had approximately twenty available, including a
certified paramedic and EMTs. GVFD has only four volunteers, none of which
are certified paramedics. These volunteers respond “at will.” They are not
required to respond. Id., 1:42:15. This four person volunteer pool will receive
preference for the new hire EMT positions if GVFD is awarded a CON (further
reducing it). Id., 1:45:30.
FFFF. At the prior Washington State operations O’Donahue ran, one
utilized two ambulances to do approximately 900 transports a year. The second
utilized two ambulances to do approximately 1,600 transports a year. Yet,
GVFD is proposing to have three ambulances in service, with a fourth backup
available, to cover 800 to 1,100 per year. Id., 1:43:50.
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GGGG. While O’Donahue contends his current staff has extra time
within which to take on additional ambulance transport duties, he does not agree
that he is currently overstaffed such that a reduction in staff would be beneficial
to the taxpayers if the CON is not obtained. Id., 1:46:30.
HHHH. In discussing how his staffing model would work if one
ambulance crew was dispatched to a hazard call, such as a downed power line,
and other ambulances were out on calls, then a fire call came in, O’Donahue
stated he would “engage mutual aid.” He would also look to “on call”
employees. Id., 1:56:49. The travel time from that “on call” employee’s home to
the location of the ambulance would increase the response time. Id., 1:58:25.
IIII. Highway motor vehicle accidents severe enough to require the
response of an engine and two ambulances do occur in GVFD. Id., 2:00:05.
JJJJ. GVFD’s only employees who are on duty 24 hours a day, 7 days
a week, are the firefighters (supervisors and administrative staff are off evenings
and weekends). This is a minimum of seven employees spread over the three
stations. If a CON is obtained that number will be eight. Id., 2:02:14.
KKKK. The National Fire Protection Association recommends that a fire
engine be staffed with at least four firefighters, in order to follow the “2 in – 2
out” rule, protecting employee safety (for every 2 individuals inside a structure,
there should be 2 outside to rescue). O’Donahue is unfamiliar with the OSHA
standards for the same situation. Id., 2:03:27. However, GVFD’s model will
have, at best, two people per fire engine. Id., 2:04:50.
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LLLL. When asked whether he would need to keep an ambulance at
the scene of any structure fire in order to self-rescue, O’Donahue said this would
be “nice,” but not required. Id., 2:05:15.
MMMM. With regard to the ADHS guidance document (EMS Ex. 1),
O’Donahue provided the following information for each of the bullet point
considerations under the public necessity determination topic (p. 3):
- GVFD’s plan for a robust, on-going benchmarking and
performance improvement process that encompasses all
components of the EMS system from dispatch through arrival:
he did not identify any benchmarking or performance
improvement process current in place, GVFD will look at all
incidents responded to and use those to set benchmarks, to
look for performance improvements when they find that
appropriate, looking for patterns, whether individual or
systemic.
- A plan to collect and submit electronic patient care reports: “we
are moving down that path.”
- A plan to adopt clinical guidelines and operating procedures for
time sensitive illnesses consistent with best practice guidelines:
all O’Donahue could say was that they would evaluate all best
practice guidelines frequently, and if they are doing a good job,
will do this less frequently.
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- A plan to initiate guideline-based pre-arrival instructions for 911
callers: O’Donahue stated this would be evaluated as well,
referencing current fire-user meetings where these issues are
discussed and their recent installation of a “pre-alert” process
(which has nothing to do with this topic). As with the former
topics, his response was perfunctory and very general. No
specifics were provided.
- Evidence of regular attendance and participation in regional
and state EMS councils – O’Donahue acknowledged they have
not attended all in the past (of the last 11, they only attended
6), but stated they would attend those regularly.
- “A plan to ensure that ambulance service will be maintained
and improved for rural communities:” no specifics were
provided other than O’Donahue’s statement that he has done
this before and will look at all aspects of how service is being
provided. No attention to any rural community outside of the
GVFD proposed service area was evident in his response.
- Assurance that GVFD’s service model will be cost effective and
not result in higher ambulance rates: O’Donahue’s response
focused on the cost to GVFD taxpayers, including his attention
to things like making sure lights are turned out, ambulances are
rebuilt, etc. Nothing was stated regarding ambulance rates or
the financial impact to anyone outside of the GVFD tax district.
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Id., 2:12:25.
NNNN. Not all of the firefighters/first responders working for GVFD live
in the district, only approximately 25% do. Id., 2:27:30.
30. Edward Racht, M.D. (first witness, Monday, 11/03/14 a.m., beginning at
0:16:30), Chief Medical Officer for American Medical Response:
A. As Chief Medical Officer, Dr. Racht is the physician who
collaborates with AMR’s clinical and operational employees on clinical issues
related to delivery of care, as well as strategy and protocols involving clinical
evidence in and out of the hospital environment, in the Emergency Medical
Services (EMS) environment, and the dispatch environment. Id., 0:17:05.
B. AMR does approximately 3.2 million patient transports per year.
Id., 0:18:07.
C. Dr. Racht established his clinical qualifications in the EMS area, as
summarized on his Résumé (RMI Ex. 13), including medical licensure in two
states, his doctoral degree, and his career path that quickly led to a
concentrated focus on pre-(out of) hospital care such as system design and
developments, and all clinical components. He became AMR’s Chief Medical
Officer in 2010 and serves on many committees and boards related directly to
the clinical aspects of pre-hospital medicine. Id., 0:18:32.
D. Racht’s position requires him to stay up to date on pre-hospital
medicine science and trends. Id., 0:25:45. His role is to help develop
consensus on the evidence, to identify when the evidence changes and how it
may be applicable to EMS, and then work with his colleagues to develop
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protocols, quality assurance, education, and practices so that all AMR
practitioners have access to the very best available evidence and protocols. Id.,
0:25:10.
E. As part of this, he helps create and maintain standards, helps
creates policies and protocols necessary to maintain awareness of clinical
evidence as concepts evolve. He assists local medical directors in creating
benchmarks to maintain performance standards of local units, and also looks to
those local units to help the national knowledge and assist in developing best
protocols, giving the example of AMR’s recent involvement in developing
policies and protocols associated with the transportation and care associated
with patients known to or suspected of having EBOLA, which includes protocols
associated with “donning and doffing” equipment. The goal is to have all AMR
employees be prepared. Although there are few anticipated EBOLA patients,
the implications are big. Id., 0:26:45.
F. AMR has developed practices and policies for its individual
business units, including River Medical, with regard to potential EBOLA contact,
including specific guidelines from the 911 dispatch point on down the line. This
includes video education programs. All of these practices and policies are
consistent with information/guidance from the National Center for Disease
Control (“CDC”). Id., 0:32:55.
G. AMR shares the knowledge it develops on a national basis, not
only with AMR employees and business units, but also with anyone else who
wants to access the information. Id., 0:35:38.
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H. Dr. Racht does on occasion become involved with local business
units, depending upon what the local practice wants or if the organization sees
data indicating a greater need for education or follow-up. Id., 0:36:29.
I. The cornerstone of AMR’s best clinical practices philosophy is that
of operationalizing evidence based practices. The science of the clinical
practice is usually the easiest part. For example, everyone knows that EBOLA
is spread through direct bodily fluid contact. Knowing that science, the evidence
will direct how practitioners should proceed. The “art” is how to make that
happen. This is “operationalizing” an evidence based practice. Id., 0:39:35.
J. EMS medicine has greatly evolved from what was considered
simply a transport service in the 1980s. A good example comes out of Arizona,
which set the “gold standard” for practices that improve cardiac arrest survival in
the pre-hospital context, thereby decreasing mortality rates and changing the
outcome of a cardia arrest by integrating with healthcare systems, and making
sure the patient is taken to the right place with the right therapy. Id., 0:40:30.
K. EMS medicine is no longer simply a vehicle (ambulance) moving a
sick patient to an emergency room. It has become mobile healthcare, which has
improved morbidity and decreased mortality. Id., 0:42:30.
L. AMR works in partnership with the American Heart Association
(AHA). Other than the VA, AMR has the largest AHA training center in the
country. Id., 0:43:07.
M. AMR’s pre-hospital providers see an estimated 10% of the nation’s
cardiac arrest patients. Id., 0:43:30. This dovetails with AMR’s involvement in
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the CARES (Cardiac Arrest Registry to Enhance Survival) program, which
involves a registry that focuses on interventions that make a difference, and
survival trends. Participation is voluntary. It requires the introduction of
information into the registry from the pre-hospital setting through to the hospital,
which enters information regarding neurological survival. The purpose is to lay
out data, to look at a community and see what can be improved, who is doing a
good job, what is enhancing surviving. AMR has committed all of its business
units to participation, including River Medical. This allows a summary
assessment of a practice. For example, if it is seen that there is low bystander
CPR assistance, this can be addressed. This allows fine tuning of a practice.
Nationally, CARES has increased cardiac arrest survival. Id., 0:44:38.
N. RMI Ex. 14I contains AMR’s CARES data for 2012. The second
page shows national group data, and then compares it to the AMR business
units’ performances. Looking at the national data allows each individual AMR
business unit to benchmark itself against national averages. Id., 0:48:17. Over
the past three years, AMR, as a whole, has exceeded the overall national
CARES data statistics for neurologically intact survival rates. For the past two
years, it has exceeded the bystander CPR initiated rate. Id., 0:49:40.
O. AMR has focused on improving data collection, at the local
business unit level, as it relates to things that matter in pre-hospital medicine.
Three years ago, as part of the evolution of EMS, AMR realized it needed to
evaluate its ability to provide care based upon what the evidence suggested was
appropriate. It spent approximately 1-1/2 years using internal and external
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statistics to identify where EMS could make a difference, what data should be
captured in order to help benchmark this, and how to focus its efforts to improve.
It ended up with a list of “things that matter.” These are disease or injury states
where EMS can reduce mortality, areas that have specific interventions
available, and areas that are measurable. AMR focuses its EMS efforts on
these. Local practices are able to benefit from this national effort. Id., 0:50:45.
P. Those “things that matter” are ensuring safe patient care and
transport, cardiac arrest resuscitation, reduction of pain and discomfort, safe
and effective maintenance of airway and ventilation, relief of respiratory distress,
recognition and treatment of STEMI and stroke, and effective and timely trauma
care (see, RMI Ex. 14B). One example is pain management. AMR discovered
that using a single measurement of pain was not optimal. A second
measurement was needed to see if pain was being reduced. Two scores for
pain and discomfort are now required of all AMR business units. Id., 0:53:15.
Q. AMR’s focus on patient safety includes effective documentation
of communications when a patient is transferred from one healthcare provider to
another. Id., 0:57:48.
R. RMI Ex. 14E details the result of a spring 2014 patient experience
survey (mailed out to 2,000 patients) showing local AMR business units out
performing their state averages in patient experience ratings, including very high
ratings respect, politeness and overall communications.
S. RMI Ex. 14F summarizes AMR’s role in national CPR training.
This is important because the impact of bystanders in saving lives, in sudden
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cardiac arrest contexts, is “huge.” This makes “chest compression only” CPR
important. Id., 0:59:05. AMR believes that if it can train the public, on a large
scale, it can make a big difference. AMR decide to take one day and do a
“world challenge,” seeing how many potential bystanders could be trained. In
2013, 54,349 were trained. In 2014, 59,286 were trained. No other organization
is doing this volume of training. Id., 1:02:05.
T. AMR is using the CPR world challenge data to create competition
between its regions, and to let all of them know where they stand with regard to
others. Id., 1:04:45. AMR’s participation in this program led to a prestigious
award from the business community – the Silver Stevie Award, which is a
corporate social responsibility award (see, RMI Ex. 14H). Id., 1:06:00.
U. River Medical trained 1,805 individuals during the recent 2014
national CPR challenge (see, RMI Ex. 14F, at Bates No. 0277). Id., 1:13:03.
V. Racht addressed the suggestion that first responders “handing off”
patients negatively impacts River Medical’s ability to provide the best clinical
care. He testified that everywhere in medicine – whether it be an operating
room, a clinical setting, or EBOLA Case No. 1, the “hand-off” is a normal part of
the healthcare encounter. Medical professionals understand that “hand-offs”
require communications, both written and verbal, to identify to the next level of
care those things that the next provider should pay attention to and be aware of.
“Hand-offs” are necessary and good, as the patient is usually going to a higher
level of care. Id., 1:06:50.
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W. There are steps taken by trained medical professionals to ensure
that transfers in the pre-hospital environment are done appropriately. This
involves three things: verbal communications must be organized and directed at
the appropriate individuals; there must be documentation (either written or
electronic), and there must always be validation by the receiving professional,
who should be doing his/her own confirmation. This last step also allows the
receiver to measure any change through their own analysis. Id., 1:08:54.
X. Racht also addressed the suggestion that increasing ambulance
arrival times would necessarily increase clinical benefits. EMS operated for a
long time under an 8 minute, 59 second response time standard for urban
environments (looking to meet this 90% of the time), which is not applicable in
rural or “frontier” environments (the appropriate standard there would be set by
the local community - in Arizona, ADHS). Id., 1:14:08. There is also literature
stating that in the sudden cardiac arrest situation, having some sort of first
response in an under 4 minute timeframe will have an impact on morbidity and
mortality (often this is bystander CPR or use of a defibrillator). However,
published material shows that the response interval does not necessarily
correlate with improved outcomes as EMS practitioners long believed. Racht
thinks there is a response interval “out there” that will define morbidity and
mortality changes for different diseases or physical states. EMS practitioners do
not yet know what specific response intervals make what kind of a difference.
Id., 1:18:10.
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Y. With specific application to an entity proposing it might respond
one or two minutes faster, Dr. Racht could not say that this would improve
morbidity or mortality rates without looking at the specific data associated with
specific conditions that were felt to not fit into the current response interval.
Without this kind of specificity, simply increasing response times cannot be
stated as definitely having an impact. Id., 1:19:50.
Z. On cross-examination, Dr. Racht was asked to speak to a report
marked as GVFD Ex. 147. However, that report is not directed at the pre-
hospital medicine environment. The issues it address occur within hospital
systems, in connection with doctor to doctor/nurse transitions. Id., 1:28:47.
AA. Racht’s responses to GVFD’s questions about whether or not he
could disagree with certain propositions were not equivalent to him stating that
he believed GVFD was engaging or not engaging in any of the practices
inquired about. He does not know of any GVFD medical providers, or what their
protocols or approaches are. He cannot comment on whether these are proper
or not. Id., 1:29:20.
31. John Valentine (second witness 11/03/14 a.m., beginning at 1:31:30,
with testimony continuing into 11/03/14 p.m., beginning at 0:2:25), General Manager
for River Medical, established the following facts:
A. Valentine has lived in Lake Havasu City since approximately 1984
and has extensive training and experience in EMS, including holding ambulance
transportation service management positions in both the fire based transport
context as well as in the private sector. He has familiarity with the River Medical
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organization going back to 1984. He continues to be certified in Arizona as a
paramedic. All of his EMS management experience has been in the western
(central) Arizona area. He worked with River Medical both before and after
AMR’s purchase. 11/03/14 a.m., 1:31:30.
B. When AMR acquired River Medical, he became the General
Manager (in approximately 2008) and has been River Medical’s General
Manager ever since. He also is currently the manager for AMR’s operation in
Blythe, California. Id., 1:42:00.
C. Prior to AMR’s Applications for Pima County and Maricopa County,
John Valentine also served as AMR’s General Manager for all of New Mexico,
oversaw a proposed start-up company in New Mexico, which serving as General
Manager for both River Medical and Blythe operations. Id., 2:01:57.
D. Valentine’s boss is the Regional CEO, Leslie Mueller. The
General Manager position is like that of a fire chief. He works with senior
leadership, which includes his Operations Manager, Brad Shelton, to benchmark
River Medical from a financial and clinical status perspective. He works with
partner fire districts including Lake Havasu City and Kingman, Arizona. He
helps develop the operations budget by working with AMR’s Regional Financial
head – Rich Bartus. Id., 1:44:00.
E. Working with Dr. Racht, he assists in getting clinical information to
River Medical staff. Racht is very accessible, even though he is “a big deal.”
Access to Racht’s experience and guidance is one of the benefits associated
with AMR’s acquisition of River Medical. Id., 1:44:50.
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F. Other benefits River Medical received through the AMR acquisition
are the general abilities to benchmark itself, from a clinical perspective, against
other operations, greater purchasing power through the benefit of the larger
organization, and access to the national fleet. AMR has approximately 4,500
ambulances throughout the country, lots of knowledge about mileage
implications, maintenance, and other issues associated with fleet maintenance.
Before AMR’s purchase, Valentine had not seen any new River Medical
ambulances for quite some time. Since AMR’s purchase, River Medical
receives between three and five new ambulances each year. This year they
also received a four-wheel drive ambulance. Given the geography that River
Medical covers, they put a lot of miles on vehicles, running just under 1 million
miles altogether last year. Getting new vehicles into the system is very
important. Currently, River Medical has approximately twenty-nine ambulances
registered (because they just received some new ones and got rid of some old
ones, he was not able to state a precise number). Id., 1:46:02.
G. When AMR takes a vehicle out of service, those old units are not
just sent to other AMR business operations. Sometimes they are donated or
sold. If they are in good condition, they will be inspected/repaired and then sent
to AMR’s FEMA fleet, which does not incur the mileage a vehicle would incur at
River Medical. Id., 1:49:25.
H. Other benefits of the AMR ownership include access to mapping
(GIS) expertise, ability to work with a system status management/deployment
expert (Doug Jones), the ability to reach out to other colleagues and obtain peer
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review through other general managers, and access to individuals at high
leadership levels, including AMR’s President, Edward Van Horne. AMR
provides Human Resources (HR), legal, billing and other “backside” support.
Id., 1:51: 38.
I. River Medical built different response zones to aid its dispatchers
in assigning ambulance transport units by zone. This lets them look closer at
response times. However, these are not built around fire districts. They are
broken into different population areas. Id., 1:54:04.
J. River Medical’s certificated response times (RMI Ex. 1 – CON) are
mandatory minimums. River Medical has always met these mandatory
minimums since being owned by AMR. Because the mandatory minimum
applies across the entire area, River Medical decided to look at different
population areas, by establishing zones, in order to see if response times could
be improved. Id., 1:55:50.
K. The River Medical service area (RMI Ex. 2B) covers approximately
9,008 square miles, despite a prior website statement of a much larger area,
which was based on the prior owner’s representation as apparently related to
upon their mutual aid coverage of a large remote California area. Id., 1:59:58.
L. The large geographic area covered by River Medical was
described (referencing RMI Ex. 38A). It bumps up against three different Indian
reservation areas that, while not included in the CON service area, are locations
that River Medical does provide ambulance transport services to. It contains a
few population centers, including Kingman, Lake Havasu City, the Yucca Fire
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District and GVFD. However, much of the service area is very rural. Other than
special event contracts, River Medical does not have any dedicated ambulance
transport units for any particular area other than the Chrysler Proving Grounds
adjacent to the Yucca Fire District, where one unit must always be stationed (it
cannot be pulled out). River Medical does a fair number of transports out of the
prison located close to GVFD. It does some ambulance transport work in the
area of the Grand Canyon Skywalk (outside its CON area). Id., 2:03:44.
M. River Medical provides significant mutual aid to the Lake Mohave
Ranchos Fire District (which also holds a CON). At one time Lake Mohave had
three ambulances to cover the large geographic area and approximately 500 to
600 calls per year. But due to declining revenue sources, and otherwise “falling
on bad times,” the fire chief was let go, along with all other department
management. The local county had to pay over $1 million to help the fire district
make its payroll. It scaled back its ambulance transport operation and currently
only runs a skeleton crew and one ambulance now. As such, River Medical has
done approximately 65 ambulance transports (year to date) either because Lake
Mohave had no ambulance available, or was operating at a below ALS level.
Id., 2:14:50; see also, id., 2:49:40. River Medical has had to turn down some of
those transports because it had no ambulances available and then Lake
Mohave had to use a helicopter transport. Id., 1:00:20.
N. All mutual aid to Lake Mohave Ranchos is 911 generated calls, no
IFTs are run out of that area. Id., 2:49:40.
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O. In the early 1990s, the GVFD area was served by a company
known as “STAT Ambulance.” That company shut down overnight and left the
area. River Medical’s owners were asked, either by BEMSTS or GVFD’s Fire
Chief, to do the ambulance transportation service on an emergency basis. River
Medical then went through the regulatory process to include the area in its CON.
Initially, River Medical shared some staffing and housing with GVFD. Then,
River Medical purchased a building to use as a station (2 ambulances were
stored in a single location). 11/03/14 p.m., 0:5:30.
P. The GVFD area, not including the roads that were added as part of
its recent expansion, is 177 square miles. The additional area it proposes to
include in its service area is 235 square miles (more than doubling the district
area). Id., 0:48:57.
Q. River Medical participates in two different forms of mutual aid –
either calls generated through the 911 system, or IFT. In Bullhead City, it
provides two ambulances for the annual “tube float,” as well as a rescue boat.
They share a mutual aid 911 agreement. River Medical does IFT transports
within the Bullhead City area when Bullhead City does not have enough units. It
does the same for the Mohave Valley Fire District. As of the end of October
2014, between those two areas, River Medical has done approximately 75 IFT
transports. To do this, the CON holder in each area must request River Medical
to respond. These IFT transports are important, because the patients are
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usually going to a higher level of care. Id., 0:07:55. The Bullhead City area
mutual aid transports are more than 90% IFTs. Id., 1:07:00.
R. If River Medical is traveling to the hospital in Bullhead City’s area,
the closest ambulance will usually be in the western part of GVFD. If an
ambulance is pulled out for that purpose, River Medical’s usual process would
be to move units within the general area such that staffing is brought back up to
approximately two units in GVFD. Id., 0:10:30.
S. If GVFD obtains a CON, it is likely that the area would not support
River Medical locating two or three ambulances there, depending upon volume,
River Medical would probably only post one ambulance to that area. This could
impact River Medical’s mutual aid responses. Id., 2:32:00.
T. River Medical’s investment in the community is not just the
ambulance transport services it provides and the national CPR challenge Dr.
Racht detailed, River Medical covers a large area with many deserving
community organizations and it tries to do the best possible community
outreach. This includes “tons of breast cancer awareness” work, golf
tournament sponsorships, and sponsorships in parades. River Medical used to
be active in GVFD area parades. Several of the River Medical staff are active in
their local chambers of commerce or other local civic activities. Id., 0:12:00.
U. Photographs were admitted into evidence showing some of these
civic activities, including River Medical’s entirely pink breast cancer awareness
ambulance, activities with the “Kingman Boomers” raising money for its Fourth
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of July celebration, and a billboard with part of the Kingman and Golden Valley
crews showing their community pride. Id., 0:14:34.
V. The area served by River Medical has access to a River Medical
devoted bariatric truck, specifically designed to transport “morbidly obese”
individuals. Without this, these patients are transported in an unsafe manner.
They are difficult to take care of and have unique medical issues associated with
their weight. Before River Medical’s dedicated unit, the closest bariatric
ambulance was located in Phoenix, and was used a lot, meaning it was time
consuming to access it for patients. All River Medical crew members are trained
on how to use the bariatric vehicle and its special features. This provides
greater safety for the patient and the ambulance crew, as well as providing the
patients the most dignity and equipment for their special clinical care issues. It
is strategically stationed in Lake Havasu City, which is the most central River
Medical location. There would either be a supervisor or associate supervisor
available, at all times, to bring the bariatric unit to the necessary location. Id.,
0:20:30.
W. Valentine disagreed that River Medical only placed a second
ambulance in the GVFD area once Chief Hewitt let them know GVFD would
pursue a CON. GVFD already had two ambulances housed in one station
within GVFD. After speaking with Hewitt, who expressed “mild” concern
regarding response times, Valentine looked at the issue, and ultimately decided
to add a second station. This probably took at least six months. The lease was
signed November 9, 2010. However, at the time Hewitt became the GVFD
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Chief, River Medical had already designated (not dedicated) two ambulances to
that general area. Id., 0:24:25.
X. Chief O’Donahue never told Valentine that he believed River
Medical had some sort of a systemic deficiency in the service it provided to the
GVFD area that he wanted remedied. In fact, Valentine asked him that question
and O’Donahue would never answer. Id., 0:34:10. This does not mean there
have not been isolated issues of concern regarding employees, from both River
Medical and GVFD, being rude or having other minor isolated issues. These
have always been addressed by both sides. Both GVFD and River Medical
employees work in high stress environments and Valentine/O’Donahue cannot
be present with every employee at all times. Id., 0:35:12.
Y. The email that Valentine sent to O’Donahue with particulars
regarding estimated costs (GVFD Ex. 77) was given in response to a request for
estimated costs. Valentine could not pull just the fire district area (because River
Medical has not built programs to allow that level of detail to be easily extracted,
pulling GVFD district area only would be very time consuming). This information
was plainly provided as an estimate. Id., 0:29:20.
Z. Early on, it was made apparent to Valentine that GVFD was
determined to obtain a CON “at any cost.” This led to communications back and
forth through email instead of phone calls, everybody watching what everybody
else said, etc. Id., 0:36:30.
AA. Valentine would not be comfortable having River Medical use
prison labor in any part of its ambulance transport services, from maintenance of
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vehicles through to billing and collections. This is because these people are
convicted felons. Cellphones are a big issue with the prison and allowing
prisoners access to ambulances or supervisor vehicles might allow access to
cellphones, as well as sharp objects and other escape issues. Valentine is also
concerned about patient information, as identity theft is a big issue.
Ambulances have narcotics (and non-narcotic drugs) which are locked, but in
the day-to-day ambulance operations, the vehicles are open. Medical
equipment could be used as weapons (needles or other sharp objects). Id.,
0:39:00.
BB. Valentine would also be concerned about River Medical’s ability to
bill Medicare if prison labor was used anywhere in the organization, because
protecting patient medical information is a large issue. He would look to AMR’s
corporate and legal compliance departments for guidance. Id., 0:43:15.
CC. All River Medical employees have background checks done before
they are hired and Medicare requires a certain screening also. Id., 0:44:11.
DD. Since AMR’s ownership of River Medical, Valentine is unaware of
any time River Medical was unable to make a reasonable and appropriate
response to a request for ambulance transport services with GVFD. Such
responses have not always come from inside the GVFD area. Id., 0:45:15.
EE. The incident Linda Vanik’s husband spoke of has its response and
arrival times documented in RMI Ex. 33A, which is a true and accurate redacted
copy of the actual patient record. As 33A indicates, Mark Vanik’s recollection of
the response times was not accurate – it only took 13 minutes. Id., 0:45:50.
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FF. Valentine has done ambulance transport service for both fire
based and private providers. He disagrees with former Chief Hewitt’s
characterization of ambulance transportation being something GVFD is already
doing, as if nothing was going to be added to the first responder duties. With
regard to the time involved, the EMS first responder portion is the shortest.
Transporting to the hospital usually takes longer and how long they must be at
the hospital depends on how busy the hospital is, whether they can find a doctor
or nurse to sign off on the necessary paperwork, how long it takes drugs to be
restocked, etc. Id., 0:50:25.
GG. Valentine’s ultimate goal is for management relationships to move
forward, past the hearing and CON process so that together GVFD and River
Medical can continue building their EMS system for the benefit of its users. Id.,
0:55:00. River Medical staff is somewhat anxious. If GVFD obtains a CON,
some of the River Medical staff is likely to lose their jobs. Id., 0:58:09.
HH. If GVFD obtains a CON, River Medical will still serve that specific
area, because of its CON. Valentine disagrees that GVFD will be able to handle
100% of the calls. River Medical is opposed to GVFD’s CON request because it
sees no need for an additional provider. The GVFD taxpayers are currently
served by a company that benchmarks itself on a local, regional, and national
level. River Medical provides high quality, high speed 911 service at no cost to
anyone other than the person using the service. Valentine is currently dealing
with a fire district (Lake Mohave Ranchos) that tried the same thing and failed.
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River Medical has put a lot of assets and jobs into the area, and performs at a
high level. Id., 0:57:05.
II. River Medical has no one to call for mutual aid, it only provides
that service. Id., 1:09:14.
JJ. River Medical’s zones are dynamic and change with the system’s
needs. Id., 1:16:25.
KK. At River Medical’s peak deployment, it runs sixteen or seventeen
ambulances. This means there are twelve to thirteen other River Medical
ambulances available for routine maintenance, repairs, “out of service” issues,
or to pull into the system as extraordinary resources. Id., 2:04:44.
LL. River Medical does provide each of its ambulances with a mobile
phone and often the employees have their own. While it is not normal for a
mobile phone to be used to dispatch, it could happen if the radio was broken or
if there were extremely high radio traffic. Id., 2:17:10.
MM. While three calls for ambulance transport services occurring
simultaneously does not occur every day in GVFD, it does happen. Id., 2:23:35.
NN. With regard to River Medical deployment, the company is looking
at this daily. Then, every six months it looks at its entire CON area as a whole,
looks at response times, what is best for the customer, and then discusses
possible deployment shifts with the River Medical team (including Doug Jones
and his AMR team). Id., 2:33:40.
OO. Before Chief Hewitt came to GVFD, River Medical had a very good
relationship with Chief Balboa and also never heard of any problems associated
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with River Medical’s response times (to GVFD’s area) or anything like that.
When both Hewitt and O’Donahue started saying they wanted three dedicated
ambulances, this was “news” to River Medical, so Valentine asked for the
reason why three dedicated ambulances were needed in the area. No response
was ever given. Id., 2:35:20; see also, id., 2:48:50.
PP. River Medical uses historical data to build its deployment models,
including IFT transports. River Medical runs approximately seven to eight IFT
transports per month out of the Bullhead City/Mohave Valley area. Id., 2:52:53.
32. Steven Athey (first witness Tuesday, 11/04/14 a.m.; beginning at
0:01:04), owner of Healthcare Visions, established the following facts:
A. Athey is an EMS consultant, who began his work in the area in
1976, as an EMT, then a paramedic. He moved on to managing a Texas
operation, then a public utility (an ambulance service operated under
government oversight) based operation in Kansas City. Next, he operated a
private ambulance company in Las Vegas. Athey then continued holding upper
management positions (CEO and Regional Vice President) for companies in
Texas and California (encompassing operations also located in Washington
State, Hawaii, Oklahoma and Arkansas), the last being with the Rural/Metro
Corporation. After the Rural/Metro position (ending in 1997), he started
Healthcare Visions. He holds a Bachelor of Business Administration, and a
Master of Business Administration. He is adjunct faculty at Texas Wesleyan
University, and previously was adjunct faculty at the University of Maryland.
Through Healthcare Visions, he focuses primarily upon ambulance services,
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working mostly with private ambulance transportation companies. Over the last
10 to 15 years between 15% and 25% of his business has been with
governmental entities (public fire departments/hospital districts). AMR is an
important client of his, accounting for approximately 10% to 15% of his
business. However, he also works for AMR’s competitors (see also, RMI Ex.
18A and 18B). Id., 0:01:42.
B. Athey was asked to review Osborn’s “Community Needs
Assessment” and render his opinion as to the effectiveness of this document as
a true assessment of need. Id., 0:09:27. No one told him what opinion or result
to try and achieve. He received the document “cold,” and read through it in
detail before discussing it with anyone. Id., 0:10:00. He reached his opinions
on his own. Id., 0:10:19.
C. While Athey said he could go through the entire document and
comment on many parts of it (id., 0:18:30), he offered some discrete
observations before getting to his overall opinions. Id., 0:11:20. These included
the following:
- At the second page of the Needs Assessment (GVFD Ex. 1 –
0128), the document discusses the “low income and educational
levels” of the community. Athey found this very unusual. Things
like this caused him to question how the document was developed,
and what the ultimate outcome would be. Cost effectiveness is
needed at all levels of income and education. Id., 0:14:25.
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- At the very bottom of the second page and on to the third (GVFD
Ex. 1 – 0128 and 0129), the document references long automobile
trips that the residents might need to make. This was remarkable
because from data (facts) one should be able to know if the area
has more accidents occurring, statistically, than other areas in the
state. However, the document contains no data, the statement is
in the demographic section when it has nothing to do with
demographics. If a “needs assessment” is going to be
based upon a notion like this, he would expect to see the
statement supported by facts showing whether there was a
higher percentage of accidents in the area. Id., 0:16:04.
- Also on page 3, under “Research Methodology,” the document
defines “unmet need” as including “the difference between the
level of service currently being provided and the needs as
expressed by the population of Golden Valley.” This is “an
incorrect statement.” Under no circumstances would this be a
definition of “unmet need.” Instead, “unmet need” would be the
“difference between the present standards already in place and
the actual performance of the system.” If there is a huge gap
between these, then you could suggest an unmet need exists. But
to say need is defined by the opinions of the area’s population is
“just erroneous.” Id., 0:17:32.
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- Also on p. 3 of the document, in addressing “adequate ambulance
coverage,” the second sentence under “Response Time and
Reliability” references the leadership of GVFD saying the area is
best served when there are three operational and available
ambulances dedicated to the area, or at least a minimum of two.
This does not make sense. It is either one or the other, but the
document never takes a solid position on that. Id., 0:18:43.
- On the third page, last paragraph, it references the Chief
emailing himself when he sees zero or one ambulance available in
the district. Throughout the entire document, and its survey tool, it
is never clear what is meant by this “zero or one” availability
standard. An ambulance transportation company serving an entire
system could find itself with zero or one ambulance available
within a specific area, but “that doesn’t mean that they are
unavailable for response.” “Ambulances cross arbitrary geo–
political lines all the time when in a bigger system.” Id.,
0:19:08.
D. As a person who does ambulance transportation needs surveys,
Athey found the underlying survey (oral and written) to be one that “led” the
respondents. It asked for their opinions on someone else’s opinion. Athey
stated his perception that it was “one-sided,” it set a tone in the vignettes read
before each question that led to the respondents to certain answers. Id.,
0:20:50.
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E. For some of the survey questions, the answer was predetermined.
For example, the described scenario of River Medical having two vehicles,
sometimes not in the area, and then making a point of commenting that one was
in a rented property and another on a street corner was dialog “completely
unrelated to a need of a system.” After laying out this scenario, asking the
respondents whether they thought three ambulances would be better than two
was of no utility. The answer from anyone (including Athey) would be yes.
However, that “doesn’t describe a need, it describes a want.” This is especially
in the context of no information being provided, in connection with the survey,
about what adding ambulances would mean insofar as finances went. Because
of things like this, Athey found the survey to be “generally unfair” and basically
designed to the get respondents’ opinions on someone’s opinion. Id., 0:21:24.
F. While Athey is unaware of any specific studies regarding evolution
of public attitudes toward fire departments, anecdotally - both on his part and in
business across the country, he is seeing a huge “ground swell of love and
support” for fire departments. He related that those individuals in private
industry fight this all the time. Fire departments are America’s heroes and it is
very difficult for private industry to find itself on a level playing field with them
when it comes to issues about who gets certain service areas, components of a
system, etc. Id., 0:22:35. He observes that only a very small segment of the
population understands that fire departments are not free. Id., 0:24:18.
G. When Athey does a needs survey, which he has done from the
biggest to smallest ambulance service providers, he starts from the point that
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“needs surveys absolutely have to be based upon some element of objective
criteria.” While opinions and wants of the general population are important to
lay a framework for change, the general public seldom knows anything about
EMS. If one surveys a population “cold” (without this background information)
the survey becomes very subjective: “it becomes a popularity contest as
opposed to really laying out what the needs of a system is.” Id., 0:24:25.
H. Athey’s objective approach, for a needs survey, has three primary
focuses, as follows:
- The number one factor is compliance with response time criteria.
In Arizona, that is the state setting requirements on CONs. This
will be the first indicator as to whether there is a problem with the
system. It includes looking at whether the operating entity has to
engage in any “artificial” means in order to maintain response time
criteria, such as over working crews, paying a lot of overtime,
relying on “exemptions” allowed by contract, or having to look to
outside entities for mutual aid in excess of the mutual aid that the
provider is giving in return. Id., 0:25:53.
- Second, Athey will go to the local EMS medical community (the
emergency room personnel, medical directors, etc.). Delayed
response times will eventually start showing up in bad patient care
outcomes and the local ER employees and doctors will have
information about what is happening at the street level. Id.,
0:29:15.
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- Athey also looks at customer satisfaction, which can be done by
way of surveys, but ones that seek opinions from people who use
the services. He will try to identify these people and meet and talk
with them. He also looks for spikes in either customer complaints
or the veracity of customer complaints. Athey elaborated that
every system receives customer complaints. No one wakes up
and knows they are going to use an ambulance. This could be
their worse day ever and for many of these people, response times
seem longer than what they might actually have been. Because of
the unpleasant experience in general, they end up not having good
feelings about the experience. What he looks for is a change in
frequency and type of complaint. Id., 0:30:06; see also, id.,
0:33:30.
I. People do not usually hire Athey when things are going well. He
gets hired when there is a problem, to go out and find objective facts to prove or
disprove that the problem exists. Id., 0:33:10. It is very rare for him to be asked
to do a needs survey when there is not a perceived problem, especially because
a needs survey is expensive. Id., 0:52:37.
J. Based upon Athey’s review of the Osborn “Needs Assessment,”
including its survey, and his experience and training/education in the area, he
found the assessment to not be useful to assess need: “it probably does a good
job of selling a project to the citizenry, but it is of no value in the needs
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assessment, as to whether or not there is a need for additional or different
ambulance services in this CON.” Id., 0:34:57.
K. Expert witness jobs are not a predominate part of Athey’s
business. Id., 0:35:30.
L. Speaking generally, Athey believes that typically if one takes a
segment of population out of a bigger service area, it can be devastating, or at
least have some degree of financial impact, to the surrounding population
because of system status management issues, lost revenue, and multiple
providers. Id., 0:37:37. He did not specifically analyze what will happen to the
current service area if the GVFD piece is pulled out, but in general, there will be
a financial impact, it is just a matter of degree. Id., 0:41:45; see also, 0:55:25.
M. While EMS, as an industry, does not “have a ton” of published (for
example in a book) standards, there are lots of best procedures and matters
those knowledgeable about the industry do consider standards. However, these
are relatively few compared to most industries. Id., 0:51:58.
33. Douglas Jones (second witness, 11/04/14 a.m., beginning at 0:57:44),
AMR’s National Director of Planning and Resource Utilization, testified to the following
facts:
A. While Jones’ college training was in electrical engineering, he
quickly moved into EMS, starting as a firefighter, and then working as an EMT,
then paramedic. He held a field supervisor position (overseeing EMTs and
paramedics) for a company purchased by AMR. He was promoted to Chief
Operations Supervisor, helped form a “start-up” ambulance business in Pueblo,
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Colorado, and then managed that. His ambulance managerial roles began in
approximately 1992. Id., 0:58:00.
B. Jones also helps analyze requests for proposals (“RFP”) to see if
AMR can create a system designed to allow it to be successful from a response
time compliance and crew workload perspective. Id., 1:07:37.
C. Approximately two and one-half years ago, AMR’s CFO created a
new position and hired Jones to fill it. Through this position, AMR’s goal is to
share its deployment/system status management practices on a national basis
with all of its operations. Jones helped develop a software platform to launch
AMR’s demand analysis tools, so all local operations can easily access accurate
deployment information when needed. This allows everyone access to the tools
Jones has developed, through a single source. Id., 1:01: 42.
D. Jones and his team of nine have been working with all of AMR’s
individual business units to write “rules” for each of those units’ Computer Aided
Dispatch (“CAD”) systems, which includes anything meaningful for each of these
units, such as certificated response times. The “rules” allow a more intelligent
level of data usage. Through this, they work to fine tune ambulance
deployment. This allows each unit to run itself better. Id., 1:04:43. There are a
number of processes available in the industry regarding geo–spatial analyses.
These are used differently by different entities. AMR’s focus is to standardize
practices based upon the best science and mathematics available, such that
each unique AMR business unit can use the best tools consistently. Historically,
the problem has been that such “tools” were lacking in uniformity. Id., 1:05:55.
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E. Jones’ team did the initial platform training work with River Medical
within the last six months. Id., 1:17:12.
F. In working with each local business unit to design its platform, the
number one thing Jones looks at is performance standards (contractual or
regulatory – CON). This will dictate the amount of resources and how those
resources should be located and scheduled. Id., 1:08:30. The geo–spatial
analysis allows him to identify the critical level of vehicles that will allow the
desired coverage, combined with a normal demand analysis, then looking at on-
task time to come up with the number of resources (ambulances) needed. To
do this, the computer analysis allows them to examine every five minute interval
during each day, each week. This involves an incredible amount of data and is
basically a more in depth analysis than anyone else is doing. Id., 1:11:06.
G. Jones has experience with both the fire based ambulance model
and the system status management model AMR utilizes. In general, fire based
uses fixed locations and resources without much dynamic posting. The problem
with this is that EMS systems are “living and breathing,” changing every single
day. The idea of fixed locations becomes difficult if the real goal is to meet the
needs of the patients. There must be flexibility. Even a single ambulance
system can have flexibility through backup plans. Id.,1:14:05:
H. The ultimate goal, when working with any of AMR’s individual
business units, is to make sure each has adequate resources so it can
successfully meet its on-time response requirements. This is important to
clinical care (getting a timely response to the patient). However, Jones does not
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get involved in finances except for to the extent he is looking to make each unit
as efficient as possible, so that resources are always available. Id., 1:12:30.
I. The fixed resource/fire based model is designed for the
convenience of the fire personnel, to be in fixed locations, parked inside, etc. If
a system is focused on the patient, it requires more flexibility. Id., 1:16:00.
J. Shifting resources within a greater system is best for the customer
base. The cost of readiness for a “fixed resource” system is not always
apparent. An ambulance transport provider manufactures “unit hours,” that are
only good for one hour, then are lost. If a single area within a greater system
wants to become static, for example, keeping dedicated resources within a small
area, that hurts how the overall system works. While ambulances might be
assigned to a zone within a larger area, those resources can be shifted based
upon need. Jones had personal experience in this regard with a fire chief who
did not want AMR to send “his” ambulances out of the fire district. When Jones
asked what would happen if another ambulance was needed in the fire district
(beyond those assigned), the chief said he would look to pull in an ambulance
from outside of his area (informal mutual aid). Jones says mutual aid only works
efficiently if it goes both ways. Id., 1:17:05. In his opinion, as opposed to a fire
based stationary model, even with some shifting of resources between stations,
and a larger system with flexible resources, that larger/flexible system “will
always be more efficient.” Id., 1:20:55.
K. When using the dynamic system status model, it is not bad or
wrong for one section of an overall area to have either zero or a lesser number
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of ambulances available for limited periods of times. This is a consequence of
the system design seen all over the country, on a regular basis. Even using the
best science available, on occasion resources in a particular area will be
exhausted. The plan is not broken if this happens. It is broken if it happens and
there are calls waiting. Usually, when a particular area gets down to zero or a
lesser number, other resources are coming in to back fill.
L. The number of transports generated from within GVFD is a
relatively small sample size that would allow analysis of number of ambulances
needed to cover the area, but would not allow geo–spatial planning. In Jones’
opinion, the GVFD area requires approximately 1.5 ambulances to cover its call
volume. Id., 1:23:20. River Medical’s service area as a whole does have
enough call volume to do a geo–spatial analysis and planning, as more specifics
are available. Id., 1:25:45.
M. The automatic vehicle locator (“AVL”) program that AMR uses
involves a “monster volume” or “massive” amount of data when it comes to
location of ambulances, which are sampled every ten to fifteen seconds. The IT
folks only allow them to keep this for 90 days before dumping it. Id., 1:26:07.
N. Jones’ review of GVFD’s “zero one” analysis does not give rise to
a cause for concern. The graph that plots availability (GVFD Ex. 1, at Bates No.
00235), assuming the subject area requires two ambulances or less to serve the
area transports, shows a very small percentage of “zero” ambulances present.
What would be as important to Jones would be to know what resources were
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available in adjacent areas for “move up” during the “zero” period. He would
also prefer to see trending over time. Id., 1:28:15.
34. Jim Wolfe (Third witness, Tuesday, 11/04/14 a.m., beginning at 1:42:32;
testimony continues as first witness, 11/04/14 p.m.), River Medical’s Operations
Supervisor, established the following facts:
A. Wolfe primarily oversees River Medical’s dispatch center and is its
main Information Technology and data analysis person. He also oversees the
dispatch center of a second AMR operation, Life Line. 11/04/14 a.m., beginning
at 1:43:05 and 1:48:00. He came to this position through an extensive EMS
background, starting as a volunteer firefighter in 1992, then joining a public fire
department as an EMT in 1994, moving through dispatch and communication
duties in both the public and private sector, and eventually joining River Medical
in October 2009. Id., 1:44:05. Wolfe assists with computer programming and
reporting data, not only for River Medical but for a communication center that
assists operations in three different states. Id., 1:49:10. He is the person at
River Medical who is most familiar with its computer stored data. Id., 1:49:48.
B. River Medical’s “zones” began being utilized after Wolfe joined
River Medical. He wanted to improve the dispatcher’s ability to appropriately
allocate resources, with the goal of reducing response times. He looked at
River Medical’s historic (handwritten) call log information to see what units had
been used when and where and for how long. While there was no need to build
geographic “zones” for River Medical’s regulatory (response time) reporting, this
was a high priority for him. He did not want the dispatchers having to look
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through maps, etc. to try to figure out which unit to send where. He wanted
there to be a geographic allocation based upon known historical data. He
looked at the Kingman area and GVFD area as one geographical area,
containing two smaller subdivisions to be watched a regular basis. Id., 1:50:22.
C. Within the Kingman/GVFD geographic area, the Kingman section
has higher volume of calls. The Golden Valley subdivision was created on the
basis of having two ambulances assigned to be there twenty-four hours a day.
However, once that was done, Wolfe observed the volume of calls was lower
than that number justified. The Golden Valley assigned ambulance units only
used about thirty-six hours of unit hours a day, which takes one and one-half
ambulance per twenty-four hour period to cover. He went to his bosses about
this. They told him to “leave it alone.” As such, River Medical kept two
ambulance units assigned to that area, but looked at what it could do to balance
out the unused unit hours, creating a zone larger than the actual fire district, to
recognize the additional availability. This zone assignment is simply a tool for
the dispatcher to look at when identifying what unit to send. Id., 1:53:17; see
also, id., 1:54:00.
D. These dispatch zones (River Medical also uses response zones
which tell them where a call is going) are continuously changing over time, their
boundaries are being adjusted based upon historical usage. In the last five
years, the Golden Valley zone has changed about as many times. Id., 1:53:33.
E. River Medical started using these dispatch zones in early 2011.
Id., 1:58:58. There are currently five dispatch zones centered on the
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communities of Kingman, Lake Havasu, Golden Valley, Parker and Quartzsite.
The zones include some large expanses of rural areas around each of these
population centers. Some also include adjacent Indian reservation areas River
Medical serves, which are not technically included in its CON area. Id., 1:59:55.
The Golden Valley zone was reduced over time because they found that a
particular unit from the Kingman area could get to the southern part of the
Golden Valley area faster, so that portion of what was once the Golden Valley
zone is now included in the Kingman dispatch zone. Id., 1:59:55.
F. GVFD Ex. 167 shows the various posting locations available in the
Golden Valley area, and others close by. Post 50 is River Medical’s only
dedicated unit – posted at the Yucca area proving grounds. Id., 2:11:28. The
Golden Valley area available postings are Posts 33, 35 and 36 (the two sub-
operation stations) and 37. Of the Kingman Posts, Post 31 is the furthest west
and closest to the GVFD area. Id., 2:13:20. However, it is a very dynamic
system, so one cannot always say where any particular unit will be. Id., 2:15:48.
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G. Wolfe gave examples of how posting locations might change in the
area, when units went into service and became unavailable. For example, in
looking at the overall Kingman/Golden Valley area, and its two sub-areas, for
dispatching purposes River Medical knows it wants to see a certain number of
units in particular areas. He described where those units would be posted in
Kingman, depending upon number of units available. This includes a unit being
moved from the GV area if Kingman were reduced to one ambulance, with the
second assigned Golden Valley unit then moving towards the center of its area.
If Kingman got down to zero units, the one GV unit would be moved, and
another unit would then be “moved up” from the Lake Havasu area. Id., 2:20:00.
H. Wolfe talked through the same general parameters for the Golden
Valley area, qualifying this with the fact that there is not a simple answer to unit
placement, it depends upon call volume, how the system is running that day,
both locally and overall. The Golden Valley posting plan is a “starting point” but
there is also dynamic movement within that plan. If only two ambulances are
available in the Golden Valley area (sometimes there are three), one is at Post
35 and one at Post 36. If one of those gets sent out, generally the other would
be sent to Post 37 and a Kingman unit would be moved to its Post 31 (on the
western edge). If the Golden Valley area gets down to level zero, a Kingman
unit is then moved to the center of the Golden Valley area. They try to not allow
that zero coverage to occur, but it can happen. Id., 2:21:50. At the end of the
day, River Medical is managing the overall geographic area of Kingman and
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Golden Valley, while watching the two sub-areas. 11/04/14 p.m., beginning at
2:24:00.
I. GVFD calculates its response times differently than River Medical.
River Medical calculates its response time from when it is alerted to the call, to
when the ambulance arrives. The ambulance does not know about the call until
it is “dispatched.” There is an interval of time between the “alert” and the
“dispatch.” GVFD calculates its response from dispatch to arrival. As such, a
GVFD 10 minute arrival is not equal to a River Medical 10 minute arrival, GVFD
has actually taken longer. Id., 00:02:16.
J. After Mr. Vanik (NuCor Steel) testified that it took 30 minutes or
more for an ambulance to arrive for one specific call, Wolfe checked River
Medical’s records and was able to locate that call. The redacted record was
admitted as River Medical Ex. 43A. This shows River Medical arriving within 15
minutes and 2 seconds of dispatch. Id., 0:00:12.
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K. Mr. Vanik also related a call for ambulance service at a restaurant
on Highway 68. With the information given, Wolfe was able to locate the call.
Vanik testified that GVFD arrived first, followed by River Medical after 5 to 10
minutes. The documentation shows this is not true. River Medical arrived within
4 minutes and 36 seconds of receiving the call,2 at 19:43:23 (military time,
hours:minutes:seconds) and GVFD arrived at 19:44:48 (see also, RMI Ex. 43B –
showing River Medical arrival; RMI Ex. 43C – showing GVFD dispatch and
arrival, which comparison also shows River Medical as dispatching over 1
minute quicker than GVFD). Id., 0:04:40.
L. On October 23, 2014, River Medical received a call from Kingman
Fire (who dispatches GVFD) asking for an response to a call for service from a
fall victim who could not walk. River Medical’s employees asked if GVFD would
be responding and the dispatcher said they would not. While the dispatchers
did not say why, Wolfe knows that at that time, on Highway 68, GVFD was
involved in responding to a motor vehicle accident. Two River Medical vehicles
were also on that scene. As such, River Medical dispatched a unit from
Kingman to take the call. This shows the system working as it should. River
Medical had a unit “moving up” to cover the area at the time. That unit came out
of Kingman. This is the benefit of a larger system with nearby units (in a
different geographical sub-area)(see, RMI Ex. 39). Id., 0:08:58.
2 Wolfe’s calculation, in his head on the witness stand, was actually wrong. 43B shows the call taken at 19:39:47 (or 7:39, and 47 seconds, p.m.) and arriving on scene at 19:43:23 (or 7:43 and 23 seconds, p.m.). This would be 3 minutes and 36 seconds.
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M. Wolfe also researched Chief O’Donahue’s testimony that once in
the previous year he had called Bullhead City to provide an ambulance
transport. Wolfe located one incident where both Bullhead City and River
Medical responded, along Highway 68 near or on the very western boundary of
River Medical’s service area, adjacent to a mountainous area. Wolfe found
O’Donahue’s testimony “unusual.” As the only certificated ambulance transport
provider in GVFD, River Medical would have to be the one to request the mutual
aid, and Wolfe had no recollection of ever doing this. Given cell towers, mobile
phones, etc. in that stretch of highway, it is possible both Bullhead City and
River Medical were dispatched. The incident involved a person sleeping in his
car. There was no transport. Id., 0:12:00.
N. Wolfe explained how he had obtained the information and
prepared RMI Ex. 7A and B, as well as RMI Ex. 8A-F showing River Medical’s
fractile response times both within the GVFD service area during the ninety day
period identified in its Needs Assessment (May through August 2012) - 7A, the
Golden Valley zone for that same period of time – 7B, and then River Medical’s
overall fractile response times for 2011 through 2013, as well as the Golden
Valley zone fractile responses for those same years (Ex. 8A-F, respectively).
While overall CON response time reports are fairly easy to run, as are the
zones, the GVFD area-only report was extremely difficult to extract and took
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Wolfe several weeks to obtain and check for accuracy. These data runs were
compared to River Medical’s CON (minimum) response time fractiles for all 911
ambulance calls, which are as follows:
- 10 minutes on 61%
- 15 minutes on 78%
- 30 minutes on 93%
- 75 minutes on 100% (with a remote area exception)
(See RMI Ex. 1)
While the CON response times are for an annual average of River Medical’s
entire service area, all of these exhibits showed River Medical as achieving
better than its certificated minimums. For example, the fire district area
response times, for the ninety day period in 2012 chosen by Applicant as the
focus of its Needs Assessment, showed River Medical achieving much better
than its certificated response times, as follows:
- Within 9:59 min. or less – 75%
- Within 14:59 min. or less – 94%
- Within 29:59 min. or less – 100%
In contrast, GVFD’s proposed response times are as follows:
- 10 minutes or less – 74%
- 15 minutes or less – 91%
- 30 minutes or less – 99%
- 60 minutes or less – 100%
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Those GVFD proposed response times must also be considered in the context
of GVFD not calculating its response interval so as to include the time between
when it receives a call and when dispatch alerts the ambulance, meaning that
River Medical’s “better than GVFD proposed” response intervals are even more
remarkable (see, RMI Ex. 1, 7A & B, 8A-F). Id., 0:16:05.
O. Wolfe also reviewed Nicole Guerrero’s “zero/1” report and graph
for accuracy (GVFD Ex. 110). Given the limited time available, he could only
spend a week of time, and just got through one month of her ninety days. Id.,
0:34:40. From a broad stroke perspective, he saw some major errors. First, she
excluded one of River Medical’s GVFD posts. Then, when River Medical was
doing a “move up,” she immediately counted that unit as unavailable, even if it
was still in the district during its travel time. This is inaccurate because such a
unit is still available for dispatch to a call, which in fact happens. For example, if
a River Medical unit was coming from its westernmost post, it could be in the
GVFD area for approximately 10 minutes. She also did not account for the
supervisor vehicle that comes into GVFD on a daily basis, which vehicle is
always a fully-staffed ambulance transport unit, available to take a call.
Similarly, she failed to account for River Medical’s posts that are just outside of
the GVFD area, which are also available for GVFD calls. 0:35:35; see also,
0:59:41. There could also possibly be an associate supervisor vehicle fully-
staffed, in the area. Id., 1:03:55.
P. Wolfe found more specific errors, for example, units that were
moved, but still in the district and missed by Guerrero, several situations where
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the times given for availability did not match up with the true vehicle tracking
information. He noticed this because at times Guerrero’s point A to point B
transit looked way too long. He saw incidents where there was more coverage
in the area than she reflected, times she showed no or one vehicle available
when there were more. Id., 00:41:05. He decided to run a report for that same
ninety day period Guerrero looked at, to see what River Medical’s average
response times were for the days where she showed level zero. He already had
that ninety day period information segregated out (RMI Ex. 7A). He then
obtained the average response time for all calls within the fire district (as it was
situated in 2012) for days Guerrero showed “level zero”; the time period of May
15 through June 25, 2012 (he stopped there because he ran out of time). Of
those 28 reports, 1 showed no calls, 4 showed an average response of under 5
minutes, 24 showed average response times under 10 minutes and the
remaining 3 (10 minutes or greater) were all under 13 minutes 12 seconds (see,
RMI Ex. 40). Id., 1:08:29.
Q. Applying the facts he knows from his regular duties, as well as
what he saw in Guerrero’s “zero/1” compilation, Wolfe best estimate is that the
GVFD charts in its Needs Assessment that show a level zero approximately 2%
of the time are in error, and that in fact that number would sit somewhere
between 1% and 1.5%. However, this does not mean there would be no
ambulances available during that percentage of time in the fire district area.
River Medical has a “vast” fleet, and since Wolfe has been with River Medical,
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there has never been a situation where it could not appropriately respond to a
call for an ambulance transport in its CON area. Id., 0:47:59.
R. Wolfe disagrees that GVFD witness Belokas would be able to
accurately determine the precise amount of ambulances available within GVFD,
as he did rely upon much of Nicole Guerrero’s data, which is simply not correct.
Id., 0:49:56. The 1% difference between Belokas’ River Medical 10 minute or
less (response time) calculations and River Medical’s calculations (RMI Ex. 7A)
is probably best explained by the difference between how GVFD and River
Medical calculate response times. Id., 0:53:55.
35. Brad Shelton (second witness, Tuesday, 11/04/14 p.m., beginning at
1:12:59; testimony continued Wednesday, 11/05/14 a.m., beginning at 0:01:05), River
Medical Operations Manager, established the following facts:
A. Shelton oversees the day-to-day operations of River Medical and
Blythe ambulance, including managing several supervisors (communications,
operations, clinical education specialist, and various levels of leadership under
them, down to the field staff). He works directly under John Valentine. 11/04/14
p.m., beginning at 1:13:20.
B. Shelton detailed his EMS and supervisory experience and
expertise, starting with his volunteer firefighter work with the Desert Hills Fire
Department in 1995, his becoming an EMT firefighter for a small fire
department, and then quickly taking on leadership responsibilities. This includes
working with the Lake Havasu Municipal Fire Department, his becoming a fully
certified paramedic (which he still is) and ultimately going to work for River
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Medical. Shortly after AMR acquired River Medical, he was hired by River
Medical to be a field supervisor (working as a paramedic on an ambulance with
an EMT partner, with field supervisor responsibilities). As of late 2008 or early
2009, he took on his current responsibilities. He lives north of Lake Havasu City
and south of Yucca. Id., 1:14:42.
C. There are things an ambulance crew might need to do within their
substation before responding to a call (after the call is received). Optimally, this
should take no more than a minute. Id., 1:23:35.
D. It is not bad for River Medical to be posted at the Maverick in
GVFD. Street corner posting is common throughout the country. The
employees have all opportunities they might have at a station, except for
television. There is food, restrooms, and opportunities to rest and meet the
community. The Maverick is a hub of activity within GVFD. Id., 1:25:00.
E. River Medical does not currently use any 48 hour shifts, other than
for the Yuma Proving Ground dedicated unit. Most employees work a 24 hour
shift, some work a 12 hour shift. In the past, there were some 48 hour shifts, but
they have tried different versions and have found the current model (working
every other 24 hours for 3 shifts, then being off for 4 days) as optimal. This
allows staff a significant amount of time to rest between shifts, and time to do
things with family and at home. This also works with River Medical’s policies
regarding fatigue. In addition to no one being allowed to work more than 36
hours, any employee may be relieved of duty at any time if he or she is fatigued.
River Medical promotes physical fitness and rest. Id., 1:26:47.
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F. River Medical supervisors do periodically follow-up with families or
patients. While there is no percentage follow-up required, if a call comes into
the office when Shelton is present, he will personally speak with the person and
either handle it himself or assign someone. Supervisors are constantly
monitoring radio traffic and might initiate a follow-up contact themselves.
Supervisors have an ample amount of discretion in this regard. Id., 1:29;26.
G. Radio traffic is not the only source of information provided to River
Medical dispatch regarding ambulance unit availability. Absent a unique
emergency or weather situation, radio is only used to dispatch ambulances.
However, “quite frequently,” dispatch will get information regarding ambulance
unit availability in a manner other than over the radio, although that is not River
Medical’s preferred way to have it handled. For example, a crew might call
dispatch to obtain certain information it needs, and at the time say “by the way,
we are now available,” or a crew might be on route to their assigned area, might
forget to radio in their position, and then call dispatch either while en route or
when they get to their posting location. Even if a crew does not radio in its
position or call, dispatchers have real time Automatic Vehicle Locator
information/GPS and can look at that to see where the crew is. Id., 1:34:24.
H. The majority of ambulance transports done out of the GVFD area,
go to Kingman Regional Medical Center, Shelton is unaware of any (either IFT
or 911) going to Phoenix or Las Vegas. Id., 1:37:40.
I. River Medical has participated in and been responsible for large
EMS incidents. Much of its CON area is rural Arizona highways, including I-40,
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and state highways 93 and 58. In the northwest section, there are significant
tour operations. He can recall tour bus accidents and an Amtrak accident,
sometimes involving 30 or more people. At times, there is no local fire
department responding and River Medical assumes incident command
responsibility. If multiple ambulances are required, River Medical has many
options. It can look to its mutual aid partners, such as Bullhead City. It can
bring in AMR vehicles from Las Vegas to the northwest, Life Line along the
eastern edge, and Blythe and Riverside County ambulance operations to the
southwest. Id., 1:41:00.
J. River Medical has worked with the prison near Kingman to put
policies and procedures into place in order to address both the prison’s needs
and River Medical’s needs, most of which focus on safety. Shelton detailed
some of these, including having an unarmed guard ride in the ambulance, an
armed prison guard following in a chase car, special accounting for all
equipment on the ambulance, especially that which might be used as weapons
or escape items, and having the ambulance staff wait once it arrives at the
hospital until the armed guard is at the ambulance doors, in order to prevent an
escape. Staff periodically report into dispatch, and dispatch will call them if they
have not heard from them within a certain time interval. Id., 1:46:08.
K. The prison riots leading to development of the policies occurred in
approximately 2010. River Medical annually does a roughly estimated 40
transports out of the Kingman area prison. 11/05/14 a.m., beginning at
00:03:00.
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L. If River Medical arrives on scene first, at the same time, or even
within a couple of minutes of GVFD, there is no “hand-off” occurring between
the two agencies. The first minute or two usually involves pulling equipment
from a vehicle, talking to family or bystanders, etc. before any treatment is
started. Lots of times, both entities treat the patient together. 11/04/14 p.m.,
beginning at 2:00:15. When there is a transfer of the patient from the first
responder to the ambulance crew, these “trained professionals” have verbal and
written communications regarding the patient and any treatment, signs,
symptoms, or past medical treatment as well as anything that has taken place
with the providers. Then the receiver (River Medical) does its own assessment
and verification of this information. When River Medical arrives at the hospital,
the same process takes place, with the hospital being the receiver. Id., 1:58:20.
M. River Medical is on scene before GVFD approximately 20% of the
time. Regardless of who arrives first, the first responders and an ambulance
transport crew work together to take care of the patient, synergistically. No one
is standing around. Id., 1:50:50.
N. Family and friends (of patients) arrive at the hospital before River
Medical “all the time.” This can be caused by them departing the scene first, or
being so worried that they are driving faster. Or, they may have been at a
different location. Id., 1:54:17.
O. There are reasons an ambulance might pull over during a
transport, depending upon the patient’s clinical needs and road conditions, for
example, to insert an IV or do an intubation. Additionally, the majority of River
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Medical transports are not done “lights and sirens.” For the comfort and safety
of patient and crew, and or the public’s safety, River Medical follows traffic laws
unless they have a critical patient. The ride in the back of an ambulance is best
likened to that of a pickup truck. Id., 1:51:55.
P. Shelton has no indication that field staff have been unable to work
professionally and well together during this CON process. Everything he has
heard indicates that GVFD staff do not support the CON. Id., 1:55:25.
Q. Some River Medical employee live in the GVFD area. Id., 1:56:45.
R. River Medical consistently attends the western Arizona EMS
Council meetings. There is always at least one representative there, usually two
to four. For many years, River Medical has co-sponsored paramedic and EMT
refresher courses for that council. A River Medical employee, Mike Caswell, has
held a Board position close to twenty years. Id., 1:56:55.
S. Shelton characterizes Dr. Racht as a “phenomenal” resource to
River Medical. He is extremely available. Id., 2:01:40.
T. Shelton detailed the problems with GVFD’s proposed staffing
model, should it receive a CON. Given his experience and knowledge, adding
four additional employees will not allow them to continue providing the fire
services they currently provide, and also provide three full-time ambulances.
“One or the other is going to have to give.” He diagramed out the number of
employees per station for vehicles, and showed what was lacking. Because
GVFD uses three shifts (A, B & C) to cover each of its stations, it takes six
people to run one ambulance 24/7. That means eighteen to run three. If they
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are fully-staffed, fire will be lacking. Today, if there is an ambulance call in the
GVFD area, the patient will usually receive a first responder (a fire response
with two employees, one of whom is always a paramedic) and an ambulance
(two employees, at least one paramedic). If GVFD stops being the first
responder, and only an ambulance arrives, there will just be one paramedic and
one EMT on scene. While this may be okay for some calls, for many, it is not.
In addition to patient care, there are patient transfer issues. For example,
mobile homes, travel trailers, and other tight spaces make it very hard to move a
patient who is heavy with just two people. Id., 2:03:40.
U. Shelton is unaware of River Medical, since AMR’s purchase, ever
not being able to send a reasonable and appropriate ambulance transport
response. It is “absolutely” his job to know if this occurs. Id., 2:12:49.
V. While GVFD tried to create an issue with regard to River Medical’s
response to the Off Road Dinner response Mr. Vanik spoke of, implying the
ambulance came from seven miles away, so it could not have arrived in less
than four minutes, Mr. Shelton explained it is possible the crew could have put
themselves out of Station No. 35 and not told the dispatcher when they went
elsewhere. Id., 2:53:37. GVFD’s suggestion was also contrary to Mr. Vanik’s
recollection, supra, that the responding ambulance came from a station
approximately one-quarter of a mile away.
W. No specific River Medical policy directs when an ambulance must
use the radio to identify itself as “available.” Ambulances must change radio
frequencies when going from larger geographic areas to others (for example,
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from the Kingman/GV area to Havasu). Generally, the ambulances do notify
dispatch when they move within those geographically areas, but this is practice
not policy. 11/05/14 a.m., beginning at 00:04:39.
X. One cannot tell from looking at GVFD Ex. 110 whether Guerrero’s
“available in district” classification defines when an ambulance crossed the
GVFD district boundary, or arrived at its post. One would need to look at
additional information to get this. Id., 0:6:34.
Y. Ambulance “unit” numbers do not correspond to ambulance
posting (location) numbers. Post No. 33 does not equal Unit No. 33. In general,
the ambulance units assigned to the GV area are Units No. 35 – 38. Id., 0:7:34.
Z. Ambulance unit numbers do not correspond to specific vehicles.
They represent personnel, location and shift assignments. The vehicle can
change daily. Id., 0:16:23.
AA. From Ex. 110, it cannot be determined whether Guerrero’s location
of ambulance Unit No. 30 (the supervisor ambulance) had its location identified
by its assignment (Kingman) or where it actually was. Additionally, Shelton
noticed other problems with GVFD Ex. 110, including Guerrero’s identification of
a movement from Post No. 33 to Post No. 37 as a “move up” (unavailable),
which is inaccurate as both Posts are in the GVFD area. Id., 00:09:00.
BB. The AVL is one of the tools dispatchers have available to
determine which ambulance to send to a call. They also have all units in the
River Medical CON and Blythe area on a large TV screen in front of them, in
real time, and the CAD entered data containing zone and assignment
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information. The CAD recommends an ambulance, and the dispatchers look at
the AVL/TV screen to verify they are sending the closest and most appropriate
unit. Id., 0:12:17.
CC. The white areas on the map of River Medical’s entire CON area
(RMI Ex. 2A and B) could be tribal land/national wild life areas. If no CON
provider is certificated to cover those areas, someone would step in. Id.,
0:14:21.
DD. Despite Nicole Guerrero’s “zero” calculation showing 7 calls
occurring when there was no River Medical ambulance within the GVFD area,
River Medical was never unable to respond in a timely manner. If in fact there
were no River Medical units within that specific boundary, River Medical still has
several ways to respond, perhaps “even faster” out of district. Id., 0:18:05.
Conclusions of Law
36. The administrative hearing was held under the authority of and pursuant
to A.R.S. '' 36-2234 and 41-1092 et seq., and A.A.C. R2-19-101, et seq.
37. GVFD has the burden to prove, by a preponderance of the evidence, that
the proposed CON should be granted. A.A.C. R2-19-119.
38. The Director of the Arizona Department of Health Services (AADHS@) and
the ADHS have jurisdiction over this matter under Arizona Revised Statutes Title 36,
Chapter 21.1, Article 2 and A.A.C. Title 9, Chapter 25, Articles 9-11.
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39. Operation of an ambulance service in the State of Arizona requires
issuance of a Certificate of Necessity (ACON@) from the Director of the ADHS. [A.R.S.
' 36-2233(A)].
40. For the Director to issue a CON, the requirements of A.R.S. ''36-2233(A)
and (B) must be met, including submission of an Application in accordance with A.A.C.
R9-25-902 and findings by the Director that public necessity requires the service
proposed by the applicant and that the applicant is fit and proper to provide the service.
41. In order to find an applicant Afit and proper,@ the Director must determine
that the applicant has the expertise, integrity, fiscal competence and resources to
provide ambulance service in the subject service area. [A.R.S.' 36-2201(21) and R9-
25-901(24)].
42. Public necessity means “an identified population needs or requires all or
part of the services of a ground ambulance service.” A.A.C. R9-25-901(45).
43. To determine whether public necessity supports the application, the
Director is to consider the applicant=s proposed response times/response time
tolerances, population demographics, geographic distribution of healthcare institutions,
and whether issuing a CON to more than one ambulance service within the same
service area is in the public=s best interests based upon the existence of ground
ambulance service to all or part of the subject area, the response times/response time
tolerances for ground ambulance services in the proposed area, the availability of
certificate holders in the subject area, and the availability of emergency medical
services in the subject area. The Director is also to consider the application
information as set forth in R9-25-902(A)(1) and (A)(2) as well as other matters
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determined by the Director or the applicant to be relevant to the determination of public
necessity. R9-25-903.
44. Those other matters determined by the Director to be relevant include the
guidance document issued by ADHS/BEMSTS (EMS Ex. 1). This includes the
Director=s interpretation of R9-25-903 as recognizing Athat the primary focus should be
on the best interests of the public and not upon protecting the territory or property
rights of current providers in the area, though the impact on the current provider(s) of
service is one of the factors to be evaluated. The Department believes that the primary
focus for the determination of public necessity is made with reference to analyzing the
needs of the community, the adequacy of the current services provided, maximizing
the use of contemporary EMS protocols that have been demonstrated to save lives and
quality of life and ensure cost controls.”
45. According to the Guidance Document, information to be considered
includes:
- A plan for a robust, ongoing benchmarking and performance improvement process that encompasses all components of the EMS system from emergency medical dispatch through emergency department arrival;
- A plan to collect and submit electronic patient care reports
consistent with BEMSTS guidelines; - A plan to adopt clinical guidelines and operating procedures for
time sensitive illness consistent with best practice guidelines; - A plan to initiate guideline-based pre-arrival instructions for all
callers accessing 911 for assistance; - Evidence of regular attendance and participation in meeting of the
regional and State EMS Councils;
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- A plan to ensure that ambulance service will be maintained and improved for rural communities; and
- Assurance that the service model will be cost effective and not
result in higher ambulance rates.
46. In deciding whether to issue a CON to more than one ground ambulance
service for the same or overlapping service area, the Director shall consider those R9-
25-903(A) factors described above, the financial impact on existing certificate holders,
the need for additional convalescent or inter-facility transports, and whether a
certificate holder in the proposed service area has demonstrated substandard
performance. R9-25-903(B). Further, the Director shall consider the difference
between existing response times (in the proposed service area) and the applicant=s
proposed response times and a needs assessment, if one exists. R9-25-903(C).
Hearing Issues
47. Pursuant to the Notice of Hearing, the following issues were established,
and based upon GVFD=s Application package, the exhibits admitted during the course
of the hearing, the testimony of the witnesses, the issues were considered (under the
preponderance of evidence standard applied to Applicant=s burden of proof) as follows:
A. Whether public necessity requires the service or any part of the service proposed by the Applicant, and if such service would be in the public=s best interest, as required by A.R.S. '36-2233(B)(2) and A.A.C. R9-25-903.
No evidence established any deficiencies or systemic
problems with the River Medical services currently provided to the subject area. The uncontroverted evidence was that River Medical, including through its parent AMR, has considerable clinical and operational support resources, available for use in the area. Its response times consistently exceed those required by ADHS. It was also uncontroverted that River Medical has always (at least since
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AMR’s purchase of the company) been able to provide appropriate ambulance transport responses. No evidence of any problems with the quality of that service was submitted. There is no public necessity requiring the introduction of additional resources into the existing system and doing so is in fact likely to create a negative impact upon the GVFD residents, River Medical and the greater public it serves.
B. Whether the Applicant is fit and proper to
provide the services proposed, as required by A.R.S. '36-2233(B)((3).
The Applicant failed to demonstrate that it has the
clinical expertise, operational expertise, or resources to provide the proposed ambulance transportation service. Very little information was provided by Applicant regarding the individual who will be responsible for running the proposed ambulance transportation service operation or who will be responsible for clinical oversight. Such persons were not called to testify as witnesses and the one résumé submitted (GVFD Ex. 123), does not provide the necessary information. Little to no information was provided regarding the intended clinical aspects of GVFD’s proposed service. The only operational information provided was with regard to the number of employees/ambulances and station assignments/movements between stations. No information was provided regarding dispatch protocols. Finally, serious questions were raised regarding the fiscal competence of Applicant with regard to the proposed operation.
C. Whether he Applicant=s proposed service area
is in the best interests of the public, or if some other service area should be granted by the Director, as required by A.R.S. ''36-2232(A)(3); A.A.C. R9-25-902 and A.A.C. R9-25-903.
The proposed service area is not in the public’s best
interests, for reasons including the negative impact that carving out the population and businesses in the selected area is likely to have upon the surrounding rural areas, which areas GVFD’s proposed area has left River Medical to cover without a central “core” population. River Medical’s coverage of its CON service area depends in part upon the transports coming out of the GVFD area for its overall
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deployment/system status management planning. Removing the population and business clusters GVFD has selected would negatively impact the adjacent, sparsely populated rural areas River Medical’s CON includes, which areas GVFD has not included in its proposed service area. It is also likely to have negative impact upon River Medical’s overall CON coverage (including but not limited to Kingman and the rural areas surrounding it), its mutual aid service to nearby fire districts, and the services it provides to the adjacent Indian reservation areas.
Further, undisputed evidence was that the number of
transports per year within the GVFD area is too small for application of current, state of the art, system status management/resources deployment calculations.
D. Whether the Applicant=s proposed rates and
charges, as set forth below, are just, reasonable, and sufficient or whether other rates and charges should be granted by the Director, as required by A.R.S. '36-2232(A)(1) and 36-2239; A.A.C. R9-902, A.A.C. R9-25-903 and A.A.C. R9-25-1101, et seq.
Proposed rates and charges:
i. Advanced Life Support Base Rate $1,295.00 ii. Basic Life Support Base Rate $1,295.00 iii. Mileage Rate (Per Loaded Patient
Mile) $ 16.42 iv. Standby Waiting Charge (per hour) None
v. Disposable supplies, medical supplies and medication and oxygen related costs Per A.R.S. '36-2239(D)
Applicant=s proposed rates and charges are likely to
result in a higher than predicted taxpayer burden (deficit). They are also based upon the rates of an unsuccessful ambulance transport operation run by a nearby fire district. The cash reserves GVFD had when it submitted its pro forma ARCR (available to cover any revenue deficits) have significantly diminished. As such, the rates and charges
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appear inappropriate. Because Applicant has failed to meet its burden with regard to other requirements of this process, additional analysis as to what rates might be appropriate is not required.
E. Whether the type and level of service
proposed by the Applicant is in the best interest of the public, as required by A.A.C. R9-25-903 and A.A.C. R9-25-901(36) and (65).
While a 24 hours a day, 7 days a week, emergency
(911) transportation service as proposed by Applicant is in the best interests of the GVFD public, that service is already being provided by River Medical and no evidence presented establishes that River Medical has failed to fully provide that service to the public’s benefit.
F. Whether the Applicant has provided or will
provide the necessary information as required by A.R.S. '36-2233; A.A.C. R9-25-902 and R9-23-903.
Applicant provided all technical requirements for a
complete application package.
Additional Issues Concerned Per the Director’s Guidance Document
48. Those additional issues identified in the Director’s Guidance Document
(listed, supra, ¶45) were in great part not addressed in a meaningful fashion by GVFD,
including but not limited to the following:
- GVFD did not adequately articulate (or detail) any meaningful plan
for a robust, ongoing benchmarking and performance improvement process for
all components of its proposed EMS operation.
- GVFD did not adequately explain why it has not acted to collect
and submit its electronic data through the Premier Aging Program, or what its
timing will be for this. It admitted it has not purchased the necessary software.
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- No detail was provided regarding a plan to adopt clinical guidelines
and operations procedures for time sensitive illnesses consistent with best
practice guidelines.
- No plan to initiate guideline based pre-arrival instructions for 9111
callers was provided.
- GVFD’s historic attendance at regional and state EMS Council
meetings has been sporadic (6 out of 11 over the past couple of years).
- GVFD did not address how its proposed operation will maintain
and improve ambulance service for Arizona’s rural communities, especially
those located adjacent to its proposed service area. The evidence presented,
instead, indicated that if GVFD becomes the ambulance transport provider for
most or all of the transports within its proposed service area, the service
provided to adjacent rural areas is likely to suffer, and even within the GVFD
proposed service area, transport users are likely to experience a reduction in
quality of clinical care and operational resources.
- GVFD’s input on a “cost effective” service model only addressed
its taxpayers’ burden, not the issue of ambulance transport rates (either within
its proposed service area or in the greater River Medical CON service area).
The uncontroverted evidence is that the River Medical CON service area not
included in GVFD’s proposed service area is likely to suffer a rate increase (or a
decrease in service). Likewise, evidence presented indicates GVFD will be
unable to maintain a financially stable operation using its proposed rates and
charges, such that an increase in those rates is likely.
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Recommended Decision
In view of the foregoing, it is recommended that the Director deny the proposed
Application, on the grounds that Applicant, Golden Valley Fire District (GVFD), failed to
demonstrate that public necessity requires any part of the service it has proposed, that
such proposed service does not appear to be in the public’s best interest, and that
GVFD did not show it has the necessary clinical/operational expertise or that it has the
required clinical, operational and financial fitness to provide the proposed ambulance
transportation services. Further, serious concern was raised regarding the likely
negative impact of GVFD taking on ambulance transport services to the current fire
and hazard services it provides. The proposed service area is not in the best interests
of the public given anticipated diminishment in resources available to the surrounding
rural areas and the fact that River Medical’s CON service area, as a whole, will also
suffer a negative impact. While not necessary to the recommended denial, it should
also be noted that Applicant’s proposed rates and charges appear insufficient to
support the proposed ambulance transportation service operation.
DATED THIS 9th day of January, 2015.
FLETCHER STRUSE FICKBOHM & MARVEL PLC
/s/ Ronna L. Fickbohm____________________ Ronna L. Fickbohm Attorney for Applicant, American Medical Response of Maricopa, LLC
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Pursuant to Case Management Order No. 1, electronic filing and service through https://portal.azoah.com/oedf/ has been done this 9th day of January, 2015. Editable (Word) version delivered via email to OAH Webmaster ([email protected]) for delivery to the Honorable Tammy Eigenheer) By: /s/ L. Clark____________