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Agenda Item
ASR
Control 23-000229 |
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MEETING
DATE: |
05/23/23 |
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legal entity taking action: |
Board
of Supervisors |
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board of supervisors district(s): |
All
Districts |
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SUBMITTING Agency/Department: |
Health
Care Agency (Approved) |
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Department contact person(s): |
Tammi
McConnell (714) 834-2791 |
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Mindy
Winterswyk (714) 834-5052 |
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Subject: Emergency Medical Services Fee
Resolution
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ceo CONCUR |
County Counsel Review |
Clerk of the Board |
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Concur |
Approved
Resolution to Form |
Public
Hearing |
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3
Votes Board Majority |
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Budgeted: Yes |
Current Year
Cost: N/A |
Annual Cost: N/A |
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Staffing Impact: |
No |
# of Positions: |
Sole Source: N/A |
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Current Fiscal Year Revenue: See Finanacial
Impact Section
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Prior Board Action: 2/14/2017 #45, 4/12/2005 #81 |
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RECOMMENDED
ACTION(S):
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1. |
Conduct a Public
Hearing. |
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2. |
Adopt a
Resolution that: |
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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. |
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b. |
Approves the
proposed Health Care Agency Emergency Medical Services Fees effective July 1,
2024, as specified in the attached draft resolution, which supersedes and
rescinds Resolution No. 17-025, Emergency Medical Services Provider Fees
Update. |
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c. |
Finds that (1)
the proposed fee meets the requirement set forth in subdivision (e)(1) and
(e)(3) of Section 1 of Article XIII C of the California Constitution of 1879;
(2) the amount is no more than necessary to cover the reasonable costs of the
governmental activity; and (3) the manner in which those costs are allocated
to a payor bear a fair or reasonable relationship to the payor’s burdens on,
or benefits received from, the governmental activity. |
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SUMMARY:
Updating the Emergency Medical
Services fee schedule, effective July 1, 2024, 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, your Honorable
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 several 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 approved on April 12, 2005, based on Board Resolution NO. 05-096. The
current EMS Program fees were approved on February 14, 2017, based on Board
Resolution No. 17-025. The Board also directed that on or about January 1,
2020, and each three years thereafter, the 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. To best
correlate with the annual County fiscal process, HCA agreed to change the rates
calculation from Calendar Year to Fiscal Year starting with the fee study for
FY 2021-22.
In accordance with the County’s
policy of full cost recovery of fee-supported programs and Board directive, the
Health Care Agency (HCA), in conjunction with the Auditor-Controller, conducted
a multi-year fee study of the Emergency Medical Services (EMS) Division. HCA
originally began this comprehensive fee study in January 2020 and worked with
the Orange County Auditor-Controller who confirmed the methodology and
completed the study September 22, 2021. However, this study was placed on hold
due to the ongoing local health emergency. A new fee study was conducted and
completed April 3, 2023, to calculate full cost recovery fees for FY 2024-25
(year 1), FY 2025-26 (year 2) and FY 2026-27 (year 3).
The actual expenditures for FY
2021-22 were used as the baseline for estimating costs for all three years. The
total estimated program cost includes salaries and benefits (S&EB) for
staff providing services and support and services and supplies (S&S). In
addition, known cost adjustments that would occur during these fee periods were
included.
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, cooperation
with EMS providers, patient advocacy, advanced medical technology and
integration of the Orange County Medical Emergency Data System.
The fee study, conducted by
Auditor-Controller, 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. The EMS fees were last updated
during Calendar Year (CY) 2017. At that time, the Board declined to assess new
hospital fees based on the argument from the Hospital Association of Southern
California (HASC) 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. Shortly thereafter, EMS validated that all
hospital base stations would continue their voluntary commitment to serve. The fee study incorporated the base station
costs into the hourly rate and therefore spread across all fees.
The EMS estimated total program
cost for FY 2024-25 is $3,871,198, and it reflects an increase of $1,044,561 or
37 percent over CY 2019 program cost of $2,826,637. Of the $3.9 million, an
estimated $2 million is the cost of fee related activities. EMS calculated full
cost hourly rate for FY 2024-25 is $141.55, which is an increase of $32.77 or
30 percent over CY 2019 hourly rate of $108.78.
The 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) increased cost for salary and employee benefit rate increases and
3) on-going maintenance cost for the Orange County-Medical Emergency Data
System.
Since the last fee update, the
total number of Full Time Equivalent (FTE) positions (including contract
positions) decreased from 15.41 in CY 2019 to 15.37 due to attrition, shifting
of responsibilities and inclusion of two new positions, EMS Coordinator and a
Research Analyst IV.
In 1988, SB12/612 authorized the
courts to assess certain court fines and penalties to be used to improve access
to and coordination of county emergency services and required counties to
establish an Emergency Medical Services Fund (EMSF) with funds distributed per
Health and Safety Code 1797.98a. In 2006, SB 1773 allowed a county board of
supervisors to levy an additional penalty to further support EMSF funding for
county emergency services and pediatric trauma care. Any fee-related emergency
services activity that is not set at full cost recovery would be offset by Net
County Cost (NCC).
SB 1773 revenues have been steadily
declining since FY 2012-13 due to the reduction of citations being issued and
is set to sunset January 1, 2027. Further, in October 2015 the Traffic
Ticket/Infractions Amnesty Program was introduced, which reduced fees owed by
50 to 80 percent. With these components and the shift toward prevention through
Traffic Enforcement education programs and media campaigns it is anticipated
that SB 1773 revenues from the courts will continue to decline. Due to this
declining EMS revenue stream and increasing operating costs, the NCC subsidy
for this program has grown from $99,628 in FY 2010-11 to $1,420,849 in FY
2021-22. The projected NCC cost in FY 2022-23 is approximately $1.1 million.
HCA proposes that all the fees
except for Emergency Medical Technician (EMT) OC Certification and Card
Replacement be set at full cost recovery for all three years in the study, as
reflected below and in Attachment B. The overall impact of setting the two fee
categories at lower than full cost recovery yielded an estimated negative
variance that will be offset using existing NCC.
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 for two full time equivalent positions dedicated program
compliance and reporting. A fee survey of similar local EMS agencies (LEMSA)
was conducted to compare the fee structure and included the following LEMSAs:
Alameda, Coastal Valleys, Contra Costa, Inland Counties, Kern, Los Angeles,
Marin, Riverside, San Diego, San Joaquin, Santa Clara and Ventura. Please see
Attachment D.
Some modifications of title and fee
structure are recommended to update correct terminology and application. The
following existing fees have been updated accordingly to reflect those changes:
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Ambulance Driver
/ Ambulance Attendant License:
Proposed to be replaced with the term “EMT Accreditation” to
accommodate for the expanded EMT accreditation process. |
Per
this table, 12 of the fees are being recommended at the full cost rate:
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Current EMS
Provider Fees |
Frequency |
Current Fee |
Proposed 2024/25 |
Proposed 2025/26 |
Proposed 2026/27 |
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Ambulance
Company License |
Annual |
$2,234 |
$4,263 |
$4,367 |
$4,485 |
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Ambulance
Unit Inspection/ vehicle |
Annual |
$160 |
$241 |
$247 |
$253 |
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Ambulance
Company Unit Re- Inspection |
Hourly |
$109 |
$142 |
$145 |
$149 |
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Customized
Data Report |
Hourly |
$109 |
$142 |
$145 |
$149 |
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EMT
Ambulance Driver/Attendant |
2 years |
$85 |
$142 |
$145 |
$149 |
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EMT
Certification (1) |
2 years |
$125 |
$125 |
$125 |
$125 |
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Card
Replacement |
Varies |
$25 |
$25 |
$25 |
$25 |
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Paramedic
Accreditation |
Varies |
$73 |
$75 |
$77 |
$79 |
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Mobile
Intensive Care Nurse |
Biennial |
$108 |
$146 |
$150 |
$154 |
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Trauma
Receiving Center |
Annual |
$9,185(2) |
$66,610(3) |
$68,238(3) |
$70,086(3) |
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Continuing
Education Provider |
4 years |
$325 |
$465 |
$476 |
$489 |
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EMT
Training Program Application |
4 years |
$923 |
$1,234 |
$1,264 |
$1,298 |
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Paramedic
Training Program Application |
4 years |
$932 |
$1,097 |
$1,124 |
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Interfacility
Transport Provider |
Annual |
$1,525 |
$1,984 |
$2,033 |
$2,088 |
(1) Does not include State pass-through fee(s)
($75 initial/$37 recertification)
(2) Triennial fee currently (does not include
annual oversight costs)
(3) Includes two dedicated FTEs for Trauma System
Compliance/Reporting
Beginning in FY 2024 HCA 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 EMS Plan pursuant to Health and Safety Code 1797.250 - 1797.254.
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New EMS Provider
Fees |
Frequency |
Proposed 2024-25 |
Proposed 2025-26 |
Proposed 2026-27 |
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Emergency
Receiving Center Designation |
Annual |
$16,886 |
$17,299 |
$17,767 |
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Children's
Receiving Center Designation |
Annual |
$16,886 |
$17,299 |
$17,767 |
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Cardiac
Receiving Center Designation |
Annual |
$16,684 |
$17,092 |
$17,554 |
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Stroke Neuro
Receiving Center Designation |
Annual |
$18,525 |
$18,978 |
$19,492 |
Full cost recovery for the new and
updated hospital fees would yield $1,117,659 in revenue. Without the adjustment
for these fees, the County subsidy will be $1,099,834 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
ensures that access to appropriate and life-saving care is provided to everyone
in our Orange County community. Attachment E outlines the proposed hospital
fees and community/hospital benefits. See Attachment F for a map that shows the
hospitals with these designations throughout the County. Without these
designations, 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 can provide the most appropriate care, would be
functioning below the medically accepted standards for EMS systems in the U.S.,
would be functioning below accepted international standards for trauma care and
Orange County's population would be at risk.
On April 14, 2023, the Emergency
Medical Care Committee (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 project is Statutorily
Exempt from the review under 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) 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)(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 cost of the regulatory activities
the EMS performs pursuant to the Emergency Medical Services System and the
Prehospital Emergency Medical Care Personnel Act (EMS Act) and charge for the
specific privileges granted to and benefits conferred upon the Orange County
EMS system providers, e.g., receiving center designation. Additionally, as
analyzed in the fee study conducted by the Auditor-Controller, the fee amounts
are no more than necessary to cover the reasonable cost of the HCA fee related
activities.
FINANCIAL
IMPACT:
Approval to increase the fees will
result in additional revenues of approximately:
FY 2024-25 $ 1,260,863
FY 2025-26 $ 35,864
FY 2026-27 $ 43,289
Fee revenue for the Emergency
Medical Services Division related to the proposed fees will be included in
Budget Control 042, HCA's FY 2024-25 budget and in the budgeting process for
future years.
STAFFING
IMPACT:
ATTACHMENT(S):
Attachment
A – Draft Resolution
Attachment B – Fee Schedule
Attachment C – Fee Checklist
Attachment D - Fee Comparison with Surrounding Counties
Attachment E – Hospital Designations
Attachment F - Map of Acute Care Hospitals by Type of Designation
Attachment G – Resolution No. 17-025
Attachment H – 2019 American College of Surgeons Trauma System Report
Attachment I – Legal References
Attachment J - EMCC Support Letter