Ambulance Advisory Committee

AMBULANCE ADVISORY COMMITTEE MEETING MINUTES February 4, 2013 3:00 PM Meeting held at: Division of Public Health & Community Services 18 Mulberry Street Nashua, NH 03060 Meeting called to order at 3:05 p.m. by Kerran Vigroux, DPHCS Director AAC Members/Designees Present: Kerran Vigroux - Director of Public Health & Community Services, City of Nashua Janet Graziano - Finance Manager, City of Nashua Steve Galipeau - Assistant Chief, Nashua Fire Department Justin Kates - Emergency Management Director, City of Nashua Denis Linehan – Captain, Nashua Police Department Fran Dupuis - St Joseph Hospital Scott Cote - Southern NH Medical Center Mark Hastings - Southern NH Medical Center AMR Representatives: Fred DellaValle, VP of Government Relations - AMR Roland Vaillancourt, AMR Operations Manager Public Attendees: None Fran Dupuis made the motion to approve the Minutes of January 18, 2013 Mark Hastings seconded the motion All in Favor – Unanimous Minutes Approved 1  Kerran Vigroux - Update o Met with the Mayor regarding the meeting on January 18, 2013 with Bill Sanger as well as Chris’ reversal of his decision to resign. Also went over the Minutes with her from that meeting. o Our job as a Committee is to oversee the current contract….is it being upheld; are issues being brought to light? It is not to develop an EMS system for the entire region. o Mayor asked that we have another Committee meeting to weigh the pros and cons of opening up the RFP Process. o Correction regarding Contract. It is in effect until September 30, 2013, with an October 1, 2013 start date. o Met with Chris Stawasz regarding his meetings with Bill Sanger regarding changes they are putting in place, meeting with Anthem, etc.  Chris met with Bill on Friday just to talk about billing and they now have two staff stationed in Manchester who are familiar with billing issues.  They have authority to enter into payment arrangements/agreements with people.  There is not a final contract agreement with Anthem yet, but they have made significant progress, and believe they are close to an agreement regarding billing, and the timing of when bills are sent to clients. o Kerran Vigroux, Janet Graziano, Finance Manager and David Fredette, Treasurer for the City, looked at the internal audit report that Manchester conducted, and at the different findings that came out of that report. David will make recommendations as to what the City should be doing regarding financial oversight.  Kerran invited the Committee members to share their opinions regarding the contract/RFP process o Scott Cote reported that he had also met with Chris Stawasz last Thursday regarding the policy of balance billing and the Manchester customer service center, as well as other concerns, including rates. Chris said that he felt that once the Anthem Contract is signed, there shouldn’t be an issue with the balance billing. o Scott asked Kerran about calls she is getting from elderly folks and billing issues. Kerran explained that the calls were primarily billing related, not level of care 2  concerns. She added that Chris has been an asset and has become involved to the point he would go to patients’ homes to assist with insurance appeals.  Steven G: They started getting increases when Rockingham went away  Kerran stated that Rockingham was subsidized by the hospital and their rates were substantially lower  Discussion with Scott and Kerran regarding these issues, especially the billing and timing it takes. Other issues were Anthem would reimburse the client at the higher rate and AMR was reimbursing funds back to client based on reduced bills, but was not aware Anthem had paid the full rate. Clients were keeping the difference. o Discussion regarding rate caps: o Scott discussed Medicare rates….125% of Medicare rates  Does an adjustment rate by AMR impact this fee cap?  Kerran: No  Rates rescinded apply to transports?  Kerran: Yes, that’s correct  Any requirement in the contract to notify in advance of rate changes?  Kerran doesn’t believe so, but will check  Scott….there should be some notification of rate increases – committee members seemed to agree on this o Discussion regarding rate caps:  Fran asked if we could cap for private carriers also.  Kerran: The City contract is only for AMR - 9-1-1 services, not transports  Roland: The contract Caps for 911 services for everyone, based on Medicare rates.  Kerran doesn’t know if AMR staff knew of the rate increases  Scott – When we looked at the RFP process a year or so ago, I felt that there should be some connection between the 911 contract and the transports taking place.  Kerran felt that seemed to go beyond the scope of the City contract and the City’s responsibility.  Both Scott and Fran felt it would be in the City’s best interest to be involved in this. 3   Scott doesn’t want to give the City more responsibility regarding transport, but feels these two are linked and that current 9-1-1 providers need better connectivity  Kerran thought that AMR or other providers need assurances from the hospitals that they will get a certain amount of business for financial security purposes and that the hospitals could choose a preferred provider  Scott referenced going out to bid…. Can the Mayor extend this for a year?  Kerran to follow up with Steve Bennett/Legal o Discussion continued regarding rates and whether the balance billing section could be removed from the contract  The City and Committee were unaware of the rate increase  AMR has since rolled back rates to pre-November  They also brought staff back o Fran requested to be given the AMR usual and customary rates and fee schedule for Medicaid/Medicare, and would like the opportunity to re-open the contract  Roland agreed to provide the Usual and Customary Rate schedule o Mark agreed with Fran and felt there is too much instability regarding the 911 ambulance service going on now not to move forward with a new RFP  There have been a lot of changes regionally with AMR, some of the things they said they could back up their Nashua things with are no longer here, and so that needs to be considered as well.  Scott feels that we need to step back and look at it all over again, due to the changes in healthcare.  Need to incorporate the transport process into those rates, so that AMR can be successful in this community.  Kerran is a little hesitant about making this contract encompass the whole EMS system by changing this contract – that there is so much more to the system than what can be addressed by wrapping it under the City contract. She does not want the burden to be on the City to fix the EMS system.  Scott said the system is working fine right now, but if we keep doing the one in three, it is not sustainable for AMR and we risk losing them.  Roland: Could we address concerns with an addendum to the existing contract rather than a whole new RFP? Would like to work within this document and address some of the concerns that have been brought up. 4   Could then look at this for the next round to build a better model by looking at models across the country, but this would take a significant amount of time to implement  Steve: Concern that the New England footprint isn’t what it was a couple years ago when AMR first took over - we were to have three 9-1-1 trucks available at all times.  We need a document that is going to encompass transport needs, hospital needs and it has to have language to protect us with the 9-1-1 events.  Justin – what is the timeframe for the RFP process?  Kerran said that it takes some time – several months – includes revising the contract and RFP, bid submission, bid review and ranking, Mayor and Board of Alderman approval  Last time AMR had only days to put their operations together, and wouldn’t want to have to face that again.  How long does it take to address the issues that need to be tackled?  Fran – when we changed over providers, didn’t we have a special extension before this went live so that everything could be ready and put into place?  Kerran stated she would have to look back at it to remember the dates but that she felt it was long.  Fran – can we put together an addendum?  Scott – I believe that if we want to make substantial changes, we can’t make an addendum  Scott – The thought process of making a connection between transports and the 9-1-1 process is not meant to add burden to the City, in fact, it is to provide more stability to that service so that there is more labor and manpower service available to respond on those days when you have those five 9-1-1 calls because there is more predictability as to what is going on. You can always delay a transport out of a hospital if that patient is stable to deal with another 9-1-1 call, so it’s the balance that I am trying to achieve. It’s intended to make smart decisions on how you are using your resources in the community so that it remains viable. How we get there, I’m not sure. But, I think we need to take some time to figure that out. And, I feel that there are some things in this contract that are flawed and need to be worked out.  Kerran – I see the value in a transport and 9-1-1 system working hand in hand, but my concern is also from a time standpoint of what you want to address in this contract right now, and how big of a task is that … are we talking about significant changes to the way things are operating that we have to work on this now, or are there things that we can button up quickly and still open up for an RFP. Are we looking at a major overhaul to the way the system is working? In that case, what is the scope of the changes that this group is 5  going to recommend? If it’s quick and manageable and we can button up some things, and it’s agreed, then maybe that is something that can be done through an addendum. If it’s much more significant and we’re changing their ability to function or capping rates that weren’t capped before, that would be a much larger task.  Fred – in many of the contracts the provider will have the first right of refusal; the city could put in the contract that offering of work to supplement the 9-1- 1. We deal with a lot of contracts.  Kerran – there are also lot of services, outside of the 9-1-1 service, required in the contract that AMR does provide free of charge.  Fred –AMR is here to make sure we are doing what is mentioned in the Contract itself.  Are there any service issues? We are committed to complying with the contract. Since you may be considering putting this out to RFP, I need to be aware of any issues.  Steve: I can tell you that since AMR has taken over we have had only a handful of minor issues and most are handled through Capt. Conway and Chris. Very minor service issues. These issues have been resolved. We have a good working relationship with Chris and you guys, and when minor issues come up, we resolve them.  Scott doesn’t feel that this is that case, because then it gets into the money, and it means that paragraphs 1, 2 and 3 that have to be up for discussion, not only is this contract, but also within the transport agreements.  Justin: Is that the only thing you see as an issue on the transport side? The costs? The hospitals would only use one provider rather than three? o Scott .. I think there are things that have to be put in there regarding back-up service. A lot of it will be cost and how things are going to be organized within the community, which changes the framework. o Kerran: Does it change significantly so that you have to open the RFP? o Scott: As I understand our City Charter and guidelines, if you change an existing contract and change the financial arrangements significantly, you have to put it back out for bid. o Kerran: This is not a contract where we pay AMR for services. So I wonder if that might….. o Scott: So that you are entering elements of control 6   Fran: I think that where we choose to go is dependent on the answers to those two questions. So if we can get an answer to those two things….  Scott: I could leave here today and say we can leave it exactly the way it is now, we’ll deal with the billing issues that come up, we can live with the transport arrangements they way they are now, but I think that will be a mistake.  Kerran: I don’t think it does the provider any service either. I know that we need a better system so that we have the best provider from a care standpoint.  Scott: We do intend to rewrite our transport agreements; we’ve learned a lot over the last year.  Kerran: Are you capping them?  Scott: We are working on doing that, yes.  Kerran: At a Medicare + whatever rate.  Scott: I think we are going to look at that differently.  Kerran: Because if you are looking to do that, then is there some way to make it consistent across the board with our contract without wrapping transports under the City’s contract?  Scott: That’s what I’m asking you.  Mark: The other thing, too, is the hospitals were non-voting consultants on the last RFP; we weren’t voting members who had any weight other that giving our thoughts and then being dismissed from the room. So that’s another reason I feel we should delve deeper into the RFP.  Fran: I can understand Scott’s perspective. Should some of the constraint be in our transport agreements? Where does it make more sense to have the constraint, in individual hospital agreements or in a City agreement, and I think the biggest issue to us is the billing issue and I think it is for the City as well. We owe it to the citizens to take a look particularly at rates charged and the way in which it is done. We have a paragraph which allows them to balance bill. I don’t think that’s appropriate; I think that’s one of the biggest issues. So, for protecting our citizens, I think we have to take a look at those pieces and look at the best way to tie them up.  Scott: It’s becoming so much more evident now that patients and consumers have obligation for the first dollar, where they never had that before. We have $5,000 deductibles for our employees over at the hospitals. So, people are watching closely where those first $5,000 are going. 7  Kerran: I will speak with Steve Bennett about if changing those paragraphs are considered material, and if so, would this require that we go out to RFP, or if it’s something we can work on as an Addendum.  Scott: Or if you made a reference to the primary transfer agreements – it could just be linked to that. (Fran agreed)  Kerran: Even if we put something in the City Contract that says AMR is the “primary transport agent” for the City, it doesn’t necessarily dictate what the hospitals do. They still don’t have the assurance that they will get the transports.  Fran: If you write it in that they will be the primary transport provider….  Justin: Your contracts will be null.  Fran: Right.  Scott (to AMR) You obviously had to increase your rates because you weren’t making costs. I think the hospitals in the City are coming together to make an agreement that this is what we want to do, and you have to make certain levels of standards – these are the levels of expectations.  Fred: I don’t disagree with the philosophy of what you are saying. Either you move forward with an RFP with an extension…do we have a year to do it, or two years to do it.  Kerran: I will check, because it doesn’t involve our revenue as a City and that’s why, to me, it might be gray.  Scott: I took issue with that during the RFP process, because I think that any decision the City is making in reference to a contract that deals with how much money people pay for a service that is regulated by the City, involves finances of the City. You’re making decisions in this contract as to how much it will cost people to be transported under a 9-1-1 agreement that involves people paying money, and it’s no different than people paying taxes. So it may not be directly coming to the City, but it directly impacts the 85,000 people who live in the City. So, I’ll look forward to what Steve has to say.  Fran (to AMR): Can we get those fee schedules as soon as possible?  Fred: Rate schedules?  Kerran: Usual and customary rates and also the fee schedule for Medicare and Medicaid.  Mark: One of the contractual agreements was that AMR will retain a large percentage of the Rockingham folks, and with all the shrinking of the footprint, it’s either my imagination or I am seeing a lot of people on the 9-1-1 trucks that we don’t know anymore. Could you get us a percentage based upon this statement.  Kerran: Does the contract say that they have to provide a certain percent?  Mark: I read it in both places. 8  Kerran: I don’t believe that the contract states that they have to employ a percent of local people.  Mark: Page 11 of the Contractor will use best efforts to staff Nashua emergency vehicles services, such as ambulances with former employees of RRA…..etc. So if I read this and then look at the response to the proposal, I am curious of what the percentage was of Rockingham folks who were retained by AMR.  Fred: Are you looking for when we made the switch, or are you looking for today or moving forward?  Mark: Today. With this footprint shrinking in New England, I notice that there are faces …. there is a union system I believe that allows people to move from place to place. I want to know how many of the Rockingham folks are gone because of that.  Fred: Our footprint is not going to shrink. We have had acquisition in the northeast. Decisions have been made…good and bad, and we have stepped in to make sure none of these decisions have caused a negative effect on any market that we are in now. Our plan is to grow. Our goal would be to keep as many Rockingham people here as possible. I don’t know how many people are in the EMS business or how many people have left for another service. We want to keep local people.  Kerran: It’s important to remember that it was so important to us at that time because we were going from a known provider in Rockingham to an unknown - AMR. Now that AMR has been here two years, how critical is it that you are holding them to something that was important two years ago?  Steve: It’s critical to us to have people who know the City. More and more I feel that it is important for people driving the ambulances to know the City.  Steve: I did make the comment that we deal with lots of issues with Chris face-to-face. Dennis…you hire people and they have to know their areas, right. Yes, during their first year they rotate through the City.  Kerran: When we see those trips that exceed the time allowed on the monthly reports …  Fran: The reports can say whatever they want them to. Do you deal with these issues face to face on a one to one basis?  Kerran: We are not seeing a lot of instances when they’ve exceeded on the reports.  Steve: Well we had that one to Chili’s  Kerran: Okay, but it isn’t something that is happening all of the time is it?  Steve: Not to my knowledge.  Fran: How often do you pull that fourth truck into service? There are times when all three trucks are tied up…there is supposed to be a fourth truck standing by for 9-1-1 work. 9   Roland: I don’t have the numbers on how often that happens; I’ll check. The contract states that we have to have a fourth truck – unmanned.  Kerran: Remember that not only is there a fourth, but there is also the Supervisor vehicle that is used  Scott: I see ambulances leaving the hospital with their lights on. Having ambulances leaving hospitals with sirens on and going to another call stresses the system.  Denis: We have more guys on the 2nd shift based on the call volume. It’s a contract issue, and our 3rd shift has the least people on.  Roland: The contract is for fixed units, not call volume. o Discussed requirements on fire/EMS training needs  Steve: There was an issue when the AMR trainer resigned but they are back on track. It has been resolved. o Steve: If we change the fee paragraphs, do we need to open the RFP? o Do we need to go out to bid; could we do a one year extension?  Modify key issues  One year to address transport  Kerran: Bob Gabriel, the Purchasing Manager is looking at the wording in the contract and checking with legal regarding terminology. o Scott suggested that we need to start again so that we can reinvent this whole thing. o Fran brought up the Contract Rates, pg. 17 paragraph 4  Kerran answered questions regarding balance billing  Roland further clarified this as well as their agreements with insurance companies.  Most insurance companies have contracts with AMR  Fred said that certain states have different requirements regarding balance billing and third party payers. o There is no law in NH that states AMR cannot balance bill.  Our Contract says that they can balance bill, so as long as it is written that way, complaints may continue.  Roland: Unless we can address it through an addendum.  Fred spoke about improved ability to address billing questions now that they have hired 2 people to staff the call center in Manchester and that will give people someone to speak to.  Mentioned example of someone being denied coverage by Medicare for service, and that there is nothing AMR can do to change that.  He acknowledged that Mayor Gatsas has been updated as to the changes that Bill and Chris are implementing. 10   AMR wants to be the patient’s advocate, they rolled back the rates, secured the work force and the management team in NH so that the good work can continue.  Mentioned great service being provided by AMR and want to move forward with this insurance issue so that people won’t have to be concerned about paying higher rates out of their pocket.  Kerran asked for a motion to adjourn: o Motion to adjourn: Fran Dupuis o Seconded: Steve Galipeau Meeting adjourned at 4:20 p.m. Respectfully submitted: Barbara Scacco Administrative Assistant II City of Nashua Division of Public Health & Community Services 11