New York Views

Mark Cunningham
EMS, One More Time
Autumn 1990

Emergency Medical Services is the city’s chronic invalid. Every couple of years or so headlines scream and patients die because New York City ambulances don’t show up on time. Then comes the big fix: The city pours out the money, pulls EMS’s performance up to New York City’s (mediocre) standards, and declares the EMS crisis resolved.

EMS has been “fixed” by the city many times. The fix lasts only long enough for public attention to wander. “After every tragedy there has been an improvement, but only with the infusion of large amounts of money,” says former City Hall administrator and Baruch/CUNY professor E.S. Savas. “Then service has inevitably declined.”

In 1980, for example, EMS’ average response time—the time it takes an ambulance to arrive after a call—stood at a horrendous 18 minutes. The city put pressure on EMS to clean up its act. By 1986, management initiatives reduced the figure to between 9 and 10 minutes. Then the backsliding began. By the summer of 1987 average response time was over 13 minutes, and over 15 minutes in the Bronx. In the summer of 1988, at least six New Yorkers died because ambulances did not arrive on time. The city embarked on another round of elaborate, expensive reform, announcing plans to add 200 ambulances, expand training, hire more supervisors, and begin emphasizing preventive maintenance—all at an estimated annual cost of $21 million. Average response time has now dropped to 8.5 minutes, 7 minutes for the most serious emergencies. The city declared itself satisfied: The EMS crisis was officially over.

Yet many other cities provide better service, at no greater cost, without eternally recurring crises. Rather than hauling EMS in for expensive minor repairs each time it breaks down, perhaps it is time for a complete overhaul: Perhaps the city should get out of the EMS business altogether, turning the job over to the sort of private EMS service that performs so well in other U.S. cities. San Diego and Fort Worth both contract their businesses out to private services and their average response times, for example, are under 5 minutes. Over the last 21 months the worst weekly average response time of Rochester’s private EMS (during an icy spell last December), was six minutes.

Nor do these other cities pay more to get first-rate service. Rochester’s EMS runs without a subsidy and charges lower fees than New York City’s. San Diego pays a subsidy of only $1.83 per capita compared with the $15.42 per capita New York City spends on EMS, although San Diego does charge users a fee somewhat higher than New York’s. (The basic New York charge is $175.)

Many New Yorkers automatically assume that anything here will be slower than in other cities. But it is not really clear why New York should trail so far behind a city like San Diego, which has a population of one million and heavy traffic problems. New York is much denser, but that should give it the edge in speed in some respects: More people live close to dispatching sites. And a large share of all ambulance calls are made at night or at other less-than-gridlock traffic hours.

How do other cities’ EMS services get ambulances to the scene so quickly? In part through intensive use of a computer-aided management technique known as “systems status planning.” Sophisticated data bases generalize from the time and places of past calls to let supervisors forecast with remarkable accuracy how many calls will come in at a particular hour from a given area. The computer then tells EMS supervisors to shift available ambulances from one neighborhood to another on a minute-to-minute (“real-time”) basis to handle unexpected surges in demand. Because demand fluctuates a lot, personnel are deployed flexibly: Extra drivers are on call in the right places and during peak hours, and shift lengths vary from six to 12 hours and occasionally as long as 18 with rest breaks.

New York, on the other hand, falls down alike on the hardware and software. EMS does use a computer program to help supervisors deploy ambulances, but the $800,000 software appears not to work well, either on the mainframe it was designed for or on the Apple II PC on which EMS runs it instead. EMS says it does schedule shifts according to formulas revised quarterly to reflect patterns of demand, but the data base appears far more primitive than that used elsewhere. Crucially, EMS computers lack real-time capability: Ambulances are deployed by unassisted humans.

An efficient emergency medical service would shift many ambulance crews from places like Wall Street by day to places like Harlem at night. New York’s service imbalances have led to charges that service is rationed according to political pull. As John Kifner reported in The New York Times last November 27, EMS keeps only four paramedic crews on call after dark north of 96th Street.

Political considerations, in the form of union demands, affect EMS’s personnel policies too. City leaders always have a rough time saying no to city workers, who vote in city elections. EMS drivers work only standard eight-hour shifts, rather than the flexible longer shifts that have proved effective in other cities. Worse, New York drivers and attendants are not primarily responsible for the maintenance of their vehicles. Maintenance is a separate union function, and it is all done at one big garage in Queens. By contrast, Las Vegas paramedics and emergency medical technicians get two weeks of training so they can do their own basic maintenance.

In well-run EMSs, ambulance fleets are usually kept something like 25 percent larger than needed during peak demand, so that vehicles can be routinely rotated for maintenance and can be pulled off duty for repairs at the first sign of trouble. In New York, by contrast, ambulance procurement, which is subject to periodic corruption scandals, is one of the easiest items to cut from the city’s perennially overstretched budget. In fact, the EMS crisis of 1988 was partly caused by a moratorium on new ambulance purchases that the city imposed to halt earlier procurement scandals: At one point during 1988, half of New York City’s aging fleet of ambulances was down for maintenance.

Rochester, San Diego, Las Vegas, and Fort Worth are among the one in seven American cities that contract out EMS service to private companies. Every private EMS provider, in fact, beats New York’s response times by a wide margin. Mercy, Inc., which handles 911 calls in Reno, Nevada, Fort Wayne, Indiana, and about half of Grand Rapids, Michigan, achieved an average response time in those cities of 4.5 minutes in 1989. Every private EMS service answers 90 percent of life-threatening calls in eight minutes or less. This 90 percent threshold is a considerably higher standard than average response-times, which are the only kind calculated by New York’s EMS.

One reason private services do better is that they are contractually obligated to do so: City contracts hold private EMS providers to explicit time standards, as well as maintenance, equipment, and training levels. Companies face financial penalties if they fall short, ranging from modest per-incident fines to forfeiture of hefty performance bonds—$700,000, for example, in Fort Worth, a city about the size of Staten Island. If a private EMS’s ambulances don’t show up on time, the company loses money. It is hard to build these kinds of incentives into any city-run service. “Can you imagine EMS being fined by another city department for every minute of extra response time?” asks Robert Forbuss, who runs a private ambulance service in Las Vegas.

“One of the greatest advantages of contracting out is that the old purchasing mechanism is taken out of the realm of politics and the bureaucracy,” says Tony Myers, who directs the city agency which oversees emergency services in Fort Worth. When the city ran its own EMS, he says, red tape hampered hiring and firing, purchasing, and other aspects of management.

Politicians must still be watched in outside contracting, of course. In New York, contracting out has sometimes been an invitation to graft, as in the Parking Violations Bureau scandals of the late 1980s. But most such scandals have occurred when a large city agency subcontracts a variety of smaller jobs with little public visibility, such as collecting overdue fines in the case of PVB. Contracting out a whole and very visible service like EMS, however, would make oversight easier because it is easier for the public and civic watchdog groups to watch one contract than a thousand smaller hiring and purchasing decisions. If the contract itself is set up right (i.e. not on a cost-plus basis), the provider has no incentive to lower its profits by driving up its own expenditures.

One modest reform step would be for New York to open contract bidding for a single borough—perhaps the Bronx, which has historically been ill—served by the city EMS. (There is no reason for an unwieldy central authority to serve all five boroughs in any case.) If Bronx EMS service becomes known as the best and speediest in the city—as it almost certainly would be—the other boroughs would begin to press for reform as well.

So far EMS reform has not made it onto the city’s agenda. The piecemeal management changes the city periodically imposes on EMS are inadequate: Indeed they often merely precipitate the next crisis, as in the ambulance procurement moratorium. EMS is a politically allocated service. It responds to political pressures that are intermittent and often contradictory. As long as EMS is run in response to pressure groups in this crisis-and-response mode, it lays itself open to charges of favoritism, which if difficult to prove are also difficult to refute.

Spokeswoman Lynn Schulman says EMS is “exploring many ideas” about how to improve service, but that contracting out is not among them. Asked about privatization, EMT union chief Richard McAllen denounces it as “profiteering on patients’ lives.” Trouble is, the taboo on “profiteering” probably is costing lives, not saving them. George Heisel, President of the Professional Ambulance Association of New York, has no doubts: “For the money New York City spends on EMS, it could have an eight-minute response time for 90 percent of life-threatening calls, and Cadillac-level medical service.” Instead, New Yorkers get a slow and politicized service lurching from crisis to crisis, trying to forget its last round of tragedies, and stumbling toward its next.

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