Agenda Item   

AGENDA STAFF REPORT

 

                                                                                                                        ASR Control  21-000880

 

MEETING DATE:

01/25/22

legal entity taking action:

Board of Supervisors

board of supervisors district(s):

All Districts

SUBMITTING Agency/Department:

Health Care Agency   (Approved)

Department contact person(s):

Tammi McConnell (714) 834-2791 

 

 

Steve Thronson (714) 834-4418

 

 

Subject:  Emergency Medical Services Fee Resolution

 

     ceo CONCUR

County Counsel Review

Clerk of the Board

Concur

Approved Resolution to Form

Public Hearing

 

 

3 Votes Board Majority

 

 

 

    Budgeted: Yes

Current Year Cost: N/A

Annual Cost: N/A

 

 

 

    Staffing Impact:

See Staffing Impact Section

# of Positions:

Sole Source: N/A

    Current Fiscal Year Revenue: See Financial Impact Section

  Funding Source: Fees: 100%

County Audit in last 3 years: No

 

 

    Prior Board Action: 02/14/2017 #45

 

RECOMMENDED ACTION(S):

 

 

1.

Conduct a Public Hearing.

 

2.

Adopt a Resolution that:

 

 

a.

Finds that the subject project is Statutorily Exempt from the provisions of California Environmental Quality Act (CEQA) pursuant to Section 21080(b)(8) of the Public Resources Code and Section 15273 of the CEQA Guidelines as the establishment or modification, structuring, restructuring or approval of rates, tolls, fares and other charges by a public agency are for the purpose of meeting operating expenses, including employee wage rates and fringe benefits; purchasing or leasing supplies, equipment, or materials.

 

 

b.

Approves the proposed Health Care Agency Emergency Medical Services Fees effective one-year after the date of proclamation ending the State of California State of emergency due to the COVID-19 pandemic, as specified in the attached draft resolution, which supersedes and rescinds Resolution No. 17-025, Emergency Medical Services Provider Fees Update.

 

 

c.

Finds that the proposed fee meets the requirement set forth in subdivision (e)(1), (e)(2), and (e)(3), as applicable, of Section 1 of Article XIII C of the California Constitution, and are therefore exempt from the definition of a tax as used therein.

 

 

d.

Finds that the revenue resulting from the fees established under the resolution will not exceed the estimated reasonable cost to provide these services.

 

 

e.

Authorizes the Orange County Health Care Agency Director or designee to adjust the fees annually by the Consumer Price Index to an amount that is no more than necessary to cover the reasonable costs of the activities/services listed in the Fee Schedule, and requires the Auditor-Controller to perform a cost recovery analysis for the Emergency Medical Services program every three years to determine the actual costs thereof.

 

 

 

 

 

SUMMARY:

 

Updating the Emergency Medical Services fee schedule, effective July 1, 2022, will enable the Health Care Agency to continue to provide local emergency medical system services throughout the County, comply with full cost recovery requirements and uphold responsibilities under California Health and Safety Code §1797.200 et seq. to regulate, monitor, plan and coordinate pre-hospital emergency medical services.

 

 

 

BACKGROUND INFORMATION:

 

On February 2, 1982, the Board of Supervisors (Board) designated the Health Care Agency (HCA) as the County Emergency Medical Services Agency (EMSA), pursuant to California Health and Safety Code Section 1797.200. Orange County is among a number of other California counties that operate their own Emergency Medical Services (EMS) Program.  The California Health and Safety Code mandates that any county with an EMS Program have a number of responsibilities, which include the following:

 

·       To regulate, monitor, plan and coordinate pre-hospital emergency medical services, hospital emergency programs and trauma centers

·       To license and monitor ambulance services

·       To license and accredit pre-hospital personnel

 

The California Health and Safety Code also permits counties to offset or recover all or a portion of their costs by establishing and charging fees to the EMS service providers.

 

The Orange County EMS Program fees were last updated for Calendar Year 2017 to 2019, based on Board Resolution No. 17-025 approve on February 14, 2017. The Board also directed that on or about January 1, 2020, and each three years thereafter, the Orange County Auditor-Controller shall perform a cost recovery analysis for the program. HCA shall review and adjust the fee schedule based  upon the Auditor-Controller's calculation of actual costs and return to the Board for consideration of the recommended fee schedule.

 

It should also be noted that at the February 14, 2017 Board meeting, the Board declined to assess new hospital fees based on the argument from the Hospital Association of Southern California that hospital base stations (online medical direction via radio contact between paramedics and nurses) were already investing significant funds to provide this service for the County.  As such, the Board directed that EMS "streamline" the process to reduce the hospital base station cost as part of the 2020 fee study. EMS has validated that all hospital base stations would continue their voluntary commitment to serve.

 

Fee Study Results and Recommendations

In accordance with the County’s policy of full cost recovery of fee-supported programs and Board directive, HCA, in conjunction with the Auditor-Controller, conducted a multi-year fee study of the EMS Division to calculate full cost recovery fees for FY 2021-22 (year 1), FY 2022-23 (year 2) and FY 2023-24 (year 3). HCA began this comprehensive fee study in January 2020 and worked with Auditor-Controller who confirmed the methodology and completed the study September 22, 2021. The actual expenditures for FY 2018-19 were used as the baseline for estimating costs for all three years, as FY 2019-20 was not reflective of a normal program year due to the COVID-19 pandemic. The total estimated program cost includes salaries and benefits for staff providing services and support and services and supplies.  In addition, known adjustments that would occur during these fee periods were added.

 

a. Fee Study Considerations - Programming

As the responsible agency for the local implementation of an emergency medical services system, EMS applies a countywide plan for high quality prehospital and emergency medical care.  Since the last fee update in 2017, several enhancements have been incorporated into the system and the oversight costs associated with these developments have been subsidized by the County general fund.  For example, EMS coordinates an integrated system of hospitals that are designated as Emergency Receiving Centers, Base Hospitals, Trauma Centers, Cardiovascular Receiving Centers, Stroke Neurology Receiving Centers and two Comprehensive Children's Receiving Centers. This comprehensive facility network provides coverage to all geographic areas of the county and assimilates the medical control directives for field assessment and rapid transport of patients to the most appropriate facility, based on standardized triage criteria.

 

These systems of care require constant, coordinated countywide oversight of quality and performance standards to ensure medical accountability. The evidence-based medical and scientific literature has shown that emergency medical services coordinated in a systematic, organized manner provides for improved care, patient safety and positive clinical outcomes for severely ill or injured prehospital patients. This coordination is achieved through local policy and procedure, mutual cooperation with EMS providers, patient advocacy, advanced medical technology, and integration of the Orange County Medical Emergency Data System.

 

The fee study analyzed the services provided by the EMS Division to determine the specific cost for each service within all fee categories, based on the type of service and staff time involved. Since the last fee update, the total number of Full Time Equivalent (FTE) positions (including contract positions) increased from 15.41 to 15.55, which included two additional staff being added to the program, an EMS Coordinator and a Research Analyst IV.

 

The EMS estimated total program cost for FY 2021-22 is $3,819,920, and it reflects an increase of $993,283 or 35.14 percent over CY 2019 program cost of $2,826,637. Of the $3.8 million, an estimated $1.9 million is the cost of fee related activities.  The EMS calculated full cost hourly rate for FY 2021-22 is $139.69, which is an increase of $30.91 or 28.42 percent over CY 2019 hourly rate of $108.78.

 

b. Fee Study Considerations – Other Sources of Funding

The non-fee related service costs are partially subsidized by Fund 13S special revenues with the remaining balance offset using Net County Cost (NCC).  Fund 13S contains deposits from MADDY and SB 1773 funds. MADDY funds are to be used for EMS as identified by the County. The SB 1773 funds are used to improve access to, and coordination of Children's Trauma and Emergency Services.  Any fee-related activity that is not set at full cost recovery would be offset by NCC. The significant increase required to achieve full cost recovery for all Program proposed fees is due to: 1) adding new fees for services that have been on-going, but for which there had been no fees charged; 2) program cost increases primarily for staffing increases, COLA increases, salary step/merit increases, and employee benefit rate increases and 3) on-going maintenance cost for the Program’s new OC-MEDS system.

 

EMS is also funded  from SB12/612 and SB 1773 funds which are assessments on certain court fines and penalties to be used to support county emergency medical services. The SB 1773 funds are to be used to improve access to and coordination of Pediatric Trauma and Emergency Services.  Since FY 2012-13 SB 1773 revenues have been steadily declining due to the reduction of citations being issued. Then in October 2015 the Traffic Ticket/Infractions Amnesty Program was introduced, which reduced debit by 50 to 80 percent. With these components and the shift toward prevention through Traffic Enforcement education programs and media campaigns it is believed that SB 1773 revenues from the courts will continue to decline. Due to this declining EMS revenue stream and increasing costs, the NCC subsidy for this program has grown from $99,628 in FY 2010-11 to $1,275,661 in FY 2018-19. The projected NCC cost in FY 2021-22 is approximately $1.1 million.

 

c. Recommendations

HCA proposes that all of the fees except for EMT OC Certification and Card Replacement be set at full cost recovery for all three years in the study.  Please see Attachment B. The overall impact of setting the two fee categories at lower than full cost recovery yielded an estimated negative variance between total proposed and the full cost recovery fee revenues.  Please see Attachment C for Revenue Comparison between proposed and full cost recovery fee for EMT OC Certification and Card Replacement.

 

A fee adjustment is necessary to address increased operational costs related to major system enhancements to improve patient care such as Trauma, Cardiac, and Stroke specialty center designations and monitoring of Interfacility Paramedic transports. As a result of the updated fee calculations, 12 of the existing 14 fees are increasing to attain full cost recovery. The Trauma Receiving Center proposed fee was changed to an annual frequency for the four Trauma Centers and includes the expenses for two additional positions. This decision was based on an American College of Surgeons report of the County Trauma/EMS system that recommended the County dedicate more positions to support the oversight and development of data systems to complement injury prevention initiatives. Recommendations from a countywide trauma consultation from the American College of Surgeons.  Further, a fee survey of similar local EMS agencies (LEMSA) was conducted to compare the fee structure and included the following LEMSAs:  Inland Counties, Los Angeles, Riverside, San Diego, Santa Clara and Ventura. Comparatively, Orange County proposed rates are within the middle range. Please see Attachment E.

 

Per the table below 12 of the fees are being recommended at the full cost recovery rate, two of the fees are being proposed at less than full cost:

 

  • EMT OC Certification: This fee is proposed to remain at $125. The proposed fee of $125 is the maximum of the six-LEMSA range. The remaining costs not recovered by the fee will be offset using existing NCC.

 

  • EMT Lost Card Replacement: This fee is proposed to remain at $25. Any card may be replaced when lost, stolen or damaged or reissued due to name change. The proposed fee of $25 is the maximum of the six-LEMSA range. The revenue impact would be insignificant because there are only 25 card replacements estimated per year.

 

 

 

Current

Proposed

Proposed

Proposed

Current EMS Provider Fees

Frequency

 Fee

2022

2023

2024

Ambulance Company License

Annual

$2,234

$4,207

$4,410

$4,457

Ambulance Unit Inspection/vehicle

Annual

$160

$237

$249

$252

Ambulance Driver/Attendant License

2 years

$85

$140

$146

$148

EMT Certification

2 years

$125

$125

$125

$125

EMT Lost Card Replacement

Varies

$25

$25

$25

$25

Paramedic Accreditation

Varies

$73

$74

$78

$79

Mobile Intensive Care Nurse  Certification

 

2 years

 

$108

 

$144

 

$151

 

$153

Trauma Receiving Center

3 years

$9,185

$65,734*

$68,900*

$69,635*

Continuing Education Provider Application

 

4 years

 

$325

 

$459

 

$481

 

$486

EMT Training Program Application

4 years

$923

$1,218

$1,276

$1,290

Paramedic Training Program Application

 

4 years

 

$932

 

$1,083

 

$1,135

 

$1,147

Interfacility Transport Provider Application

 

Annual

 

$1,525

 

$1,958

 

$2,052

 

$2,074

Customized Data Report

Hourly

$109

$140

$146

$148

*Annual frequency

 

Some modifications of title and fee structure are recommended to update correct terminology and application.  For example, statutory changes to titles such as EMT-I and EMT-P have been replaced with EMT and Paramedic.  The following existing fees have been updated accordingly to reflect those changes:

 

  • Ambulance Driver / Ambulance Attendant License: Proposed to be replaced with the term “EMT Accreditation” to accommodate for the expanded EMT accreditation process.

 

Beginning in FY 2022 the EMS Division is proposing four new fees for those subsidized activities that have been ongoing, but for which there had been no service fees. The activities are outlined in the annually updated EMS Plan pursuant to Health and Safety Code 1797.250 - 1797.254.

 

 

 

Proposed Fees

Proposed Fees

Proposed Fees

New EMS Provider Fees

Frequency

2022

2023

2024

Emergency Receiving Center Designation

 

3 years

 

$16,664

 

$17,466

 

$17,653

Cardiac Receiving Center Designation

 

3 years

 

$16,464

 

$17,257

 

$17,441

Children's Receiving Center Designation

 

3 years

 

$16,664

 

$17,466

 

$17,653

Stroke Neuro Receiving Center Designation

 

3 years

 

$18,282

 

$19,162

 

$19,367

 

Full cost recovery for the new and updated hospital fees would yield $1,102,954 in revenue.  Without the adjustment for these fees, the County subsidy will be $1,082,066 to maintain EMS program staff who directly oversee these providers. These hospital specialty designation programs have been shown by research to improve community health and well-being by decreasing death and morbidity for trauma, cardiac, stroke victims as well as children with serious emergencies. Having the designations ensure that access to appropriate and life-saving care is provided to everyone in our Orange County community. Attachment F outlines the proposed hospital fees and community benefits. See Attachment G for a map that shows the hospitals with these designations throughout the County.  Without these, EMS would be unable to monitor each hospital's ongoing compliance with specialty program requirements, would be unable to guarantee that patients are taken to hospitals that are capable of providing the most appropriate care and would be functioning below the medically accepted standards for EMS systems in the U.S., would be below accepted international standards for trauma care and Orange County's population would be at risk.

 

The proposed revenue adjustments for all programs now includes a mechanism for annual adjustments after full implementation of this proposal.  Under the proposal, starting in 2022 the fees shall be adjusted annually by the Consumer Price Index to an amount that is no more than the reasonable costs of the activities/services listed in the Fee Schedule (See Attachment B). The Auditor-Controller will perform a cost recovery analysis every three years for the Emergency Medical Services program to determine the actual costs thereof..

 

Notification regarding the proposed fees was provided to the Emergency Medical Care Committee (EMCC), ambulance companies, emergency receiving centers, fire departments and training programs.  The fee study methodology and proposed fees were discussed with hospital and ambulance industry representatives.

 

On October 8, 2021 the EMCC reviewed the proposed fee study and voted to support the methodology and forward on to the Board of Supervisors. The EMCC believes that Board policy guidance is necessary to approve the fees given the continued use of County NCC funds to provide division services.

 

Notices of Public Hearing have been published to comply with Section 66018 of the California Government Code that requires a local agency to hold a public hearing when new fees are adopted or existing fees are increased.

 

Compliance with CEQA

The subject activity is Statutorily Exempt from the provisions of CEQA pursuant to Section 21080(b)(8) of the Public Resources Code and Section 15273 of the CEQA Guidelines as the establishment or modification, structuring, restructuring or approval of rates, tolls, fares and other charges by a public agency for the purpose of meeting operating expenses, including employee wage rates and fringe benefits; purchasing or leasing supplies, equipment, or materials.

 

Compliance with Proposition 26

The proposed fee schedule does not fall within the definition of a "Tax" under Proposition 26 because it is excepted by California Constitution Article XIII C, Section 1, Subdivisions (e)(1), (2), and (3).  Subdivision (e)(1) excepts from the definition of a tax, "a charge imposed for a specific benefit conferred or privilege granted directly to the payor that is not provided to those not charged, and which does not exceed the reasonable costs to the local government of conferring the benefit or granting the privilege."  Subdivision (e)(2) excepts from the definition of tax, "a charge imposed for a specific government service or product provided directly to the payer that is not provided to those not charged, and which does not exceed the reasonable costs to the local government of providing the service or product."  Subdivision (e)(3) excepts from the definition of tax, "a charge imposed for the reasonable regulatory costs to a local government for issuing licenses and permits, performing investigations, inspections, and audits, enforcing agricultural marketing orders, and the administrative enforcement, and adjudication thereof."   These exceptions apply because the fees are established to fund the services for which the fees are charged.  Additionally, the fee amounts are no more than is necessary to recover the reasonable cost of the HCA fee related activities.

 

 

 

 

FINANCIAL IMPACT:

 

Approval to increase the fees will result in additional revenues of approximately:

 

FY 2022-23 $1,435,250

FY 2023-24 $19,339

 

Fee revenue for the Emergency Medical Services Division related to the proposed fees will be included in the budgeting process for future years.

 

 

 

STAFFING IMPACT:

 

The proposed fee schedule includes the addition of one Emergency Medical Services Coordinator and one Research Analyst IV position, effective July 1, 2022. The two positions will be added through the FY 2022-23 Recommended Budget after the EMS fees are approved.

 

 

ATTACHMENT(S):

 

Attachment A – Draft Resolution
Attachment B – Fee Schedule
Attachment C – Fee Checklist
Attachment D-  Fee Study
Attachment E - Fee Comparison with Surrounding Counties
Attachment F – Hospital Designations
Attachment G - Map of Acute Care Hospitals by Type of Designation
Attachment H – Resolution No. 17-025
Attachment I –  California Health & Safety Code Division 2.5
Attachment J -  California Code of Regulations, Division 9 Chapters 2 and 4
Attachment K -  County of Ordinance 3517 Ambulance Ordinance