Item 14 - Ambulance Rates Study and Resolution Amending and Establishing the Emergency Medical Services and Ambulance Transport FeesFebruary 15, 2022, Item #14DATE: TO: FROM: CONTACT: SUBJECT: Summary: AG EN DA REPORT City of Poway February 15, 2022 Honorable Mayor and Members of the City Council Aaron Beanan, Director of Finance . Nicole Roesler, Revenue and Operations Manager Nicole Roesler, Revenue and Operations Manager vVl.J-(858) 668-4409 or nroesler@poway.org CITY COUNCIL Ambulance Rates Study and Resolution Amending and Establishing the Emergency Medical Services and Ambulance Transport Fees A fee study for ambulance transport services has not been conducted since 2007. Fees studies are important to ensure the City's cost recovery is in alignment with the cost to provide service. For ambulance transport services they are also important to ensure the City's fee categories align with insurance reimbursement categories. As such, this staff report is for the consideration of the Ambulance Rates Study of January 27, 2022 (Attachment A) and a Resolution (Attachment B) amending the Emergency Medical Services and Ambulance Transport Fees within the Fire Department section of the Master Fee Schedule. Recommended Action: It is recommended that the City Council take public input, close the public hearing, receive the ambulance rates study report, and adopt the Resolution amending the emergency medical services and ambulance transport fees within the Fire Department section of the Master Fee Schedule. Discussion: The Poway Fire Department is committed to providing outstanding emergency medical services, fire protection services and fire prevention services to the community and is ready to respond to emergencies and disasters 24-hours a day, 365 days a year at three stations strategically located throughout the City. Resources dedicated to respond to emergency medical service type incidents are staffed by firefighters trained as paramedics. Automatic and mutual aid is also provided to adjoining agencies upon request. Of the many services provided by the Poway Fire Department, emergency medical services and ambulance transports (ambulance services) are the most frequently used by Poway residents and non-residents. Nearly 82% of all 911-calls received from a three-year period of FY17-18, FY18-19, and 1 of 29
February 15, 2022, Item #14FY19-20 involved medical related emergencies. As reflected in the adopted budget for FY21-22, funding support for the fire department includes revenue from ambulance related fees ($1,268,525), fire protection special tax ($636,000), mutual aid ($44,000), various fees associated with inspection, plan check and other safety fees ($344,552), and miscellaneous fees ($4, 1 SO) with the remaining department costs funded by the General Fund ($11,371,347). Staff completed the fee study for ambulance services to ensure that fees do not exceed the costs of providing services and recommend setting fees consistent with City financial policies. It is a best practice to complete a rates study to address changes to service deliver and costs fee study every five years. Under the terms of California propositions 218 and 26, which set restrictions on local government finance, user fees charged by the City are limited to recovering the cost of providing the related service. The last cost study that included ambulance services was performed in 2007 and fees were last updated in 2010. Operational costs for ambulance services have increased over the last fifteen years. For example, the cost of two ambulance vehicle replacements in 2007 was $350,240 compared to $509,722 in 2021, or 45.5% greater. The total operating budget for the Fire Department, excluding law enforcement, in FY06-07 was $7,850,260 compared to $13,658,574 in FY21-22, or a 73.9% increase. Additionally, there has been significant changes to the healthcare system. National healthcare reform with the Patient Protection and Affordable Care Act became law in 2010. Modifications to reimbursement policies and procedures for Medicare, Med-Cal, and private insurances make it necessary to update and modernize the fee schedule to increase the City's share of reimbursement for services. Fee Study: NBS Government Finance Group (NBS), the consultant hired to conduct the comprehensive cost of service study, was formed in 1996 and specializes in financial consulting for local governments in California. NBS prepared an Ambulance Rates Study Report with input from staff from the Finance Department and Fire Department. The fee study was conducted to update the City's costs to provide ambulance services to the community for which fees are assessed. Details of the methodology and analysis can be found in Attachment A, Final Ambulance Rates Study, summarizing the key findings and recommendations. Analysis-There were three phases of analysis completed in the fee study: 1. Cost of service analysis - A comprehensive effort to capture all associated staff time and labor costs in the Fire Department. 2. Fee establishment -This includes not only establishing the names and categories for fees but also recalibrating them to simplify the overall fee structure and to either increase the likelihood of cost recovery or make the fee structure more equitable for the community. 3. Cost recovery evaluation -Comparing the current fee for each activity to the total cost of service for that service or activity. Setting Fees-While there is no set standard to setting fees, the City has historically adjusted ambulance fees comparable to the average of other agencies in the region providing similar services. When comparing fees with other local comparable agencies, it is useful to consider the following: • They reflect the "market" cost of such fees and can assist in assessing the reasonableness of City's fees but does not reflect the cost of service incurred by Poway. • Fee surveys should not be used as the primary criteria in setting fees because there are many factors that affect how and why other communities have set their fees at their levels including 2 of29
February 15, 2022, Item #14differing cost recovery policies and procedures, basis of fees and frequency of review, and level and cost of services provided. Currently, Poway's ambulance fees are the lowest or among the lowest in the region for ambulance transports according to a calendar year 2019 survey of fees and charges of comparable agencies in San Diego County. The chart below shows the current and proposed fee for the Advanced Life Support 2 (ALS2) Resident category and where it sits in relation to the other city and special district providers in the County. As shown, Poway's ALS2 Resident fee is currently the lowest in the County. Current and Proposed Poway Fee for Advanced Life Support 2-Resident Ambulance Transport Bill Comparison ALS2 Re.sident Catecory $5,000 S--4,SOO $4,359 $4,452 $3,883 53,:00 Average= $2,461 * 51,500 $2,100 52,161 .$2,0CO Sl,535 Sl,558 51,697 _;',i~ ~/' i-,: i/'" :tf'1:,, t''' 1,i'"' b, ..... :,/'"' :,•/' t-,,,'' ,.."•.:;,, d'i_..,~ t-J"" "i'1· 1/'"' .:,:''0 b''" ,i,l' //·._ ,/-"' ~"c' ~·/•'" ,;/' ~,,o'" ,;,t>i' __ ,1,c:·' ,,~ ,o.,./" .,,er ~•-"'' ,,'5' ~,<r O d •'"4 ,/' <i'o' •-'$" •··"' ,,. ~ """' q,d' qe' ••d' q,o-~•o ~' ,, q,o ~-q' ~••"". 0,, ,,, ~ ~ *Ave,-..ge exclufts City of Pow.ty propo ,a,d fees As of 2019 S.ain Otego County Ambul..iince R.ate Survey As previously mentioned, fees have not been adjusted since 2010. As a result, cost recovery levels for the City have dropped to an average of 20%-31 %. The Poway Fire Department operates a high level of service staffing model for emergency medical services with all firefighters dually trained as paramedics and responsible for emergency response, treatment, and transport of patients. Poway is one of four cities in the county that continue to operate using this model, while other service areas are utilizing contracted transport providers or other staffing models that include single-role paramedics or emergency medical technicians with their firefighter/paramedic staff. As such, staff recommends the approval of an updated cost recovery methodology and to consider a 100% full cost recovery level. The figures in the Proposed Fees Table are based on FY 21-22 adopted budget and exclusive of the recently executed 6-year Poway Firefighters Association (PFA) contract approved after the budget was adopted. Ambulance fees were reviewed individually, compared to current market rates, and reviewed to determine the proposed adjustment to cost recovery levels. The increase in revenue will be used to partially offset annual operating expenses within the Fire Department to continue to maintain the desired service levels to the community. The Fire Department is and will continue to participate in all existing and upcoming supplemental governmental programs that provide reimbursement for ambulance transport, with the goal of helping offset the cost of providing these services. 3 of29
February 15, 2022, Item #14The table below shows the proposed fees as well as information on their cost recovery. Proposed Fees Table Fee Description Fee Proposed Proposed Current Current Unit/Type Fee Cost Fee Cost Recovery Recovery % % EMERGENCY MEDICAL SERVICES and AMBULANCE TRANSPORT Base Charge-Advanced Life Support 1 Resident Flat $4,369 100% $1,029 24% Non-Resident Flat $4,369 100% $1,366 31% Base Charge-Advanced Life Support 2 Resident Flat $4,369 100% $1,029 24% Non-Resident Flat $4,369 100% $1,366 31% Base Charge-Basic Life Support Resident Flat $4,369 100% $866 20% Non-Resident Flat $4,369 100% $1,196 27% Treatment and Release Flat $2,550 100% $150 6% ADD-ON CHARGES Per-Mile Charge Per Mile $16 $16 Oxygen Flat $66 $66 Medications Flat Cost Plus Cost Plus 50% 50% Supplies Flat $49 $49 EKG Flat $46 $46 Night Charge (7pm to 7am) Flat $50 $50 CPR Non-Transport Flat $100 $100 Extra Attendant Flat $50 $50 Cost Recovery Limitations -Most bills for ambulance services do not result in full payment. In setting fees and cost recovery, the level of use fee cost recovery should consider the public versus private benefit of the program or activity. However, there are fee collection limitations imposed by the healthcare industry that have an impact the total amount the City is able to collect from ambulance users when services are rendered. The Centers for Medicare and Medicaid Services (CMS) sets limits or caps on how much a provider can be reimbursed for administering ambulance services and private insurances pay a percentage of the costs billed which varies. While these fee limits do not preclude a provider from setting fees higher than what will be reimbursed, it does make full cost recovery infeasible. If fees are increased, the patient co-pays or deductibles remain the same, but the City will be able to bill insurance carriers for a higher percentage of the cost of service. Additionally, patients are not balance billed, a practice where a provider bills a patient for the difference between the fees charged and any amounts paid by the patient's insurer. Indexing for Inflation -Similar to other fee adjustments approved by City Council, an annual fee adjustment utilizing published industry economic factors is recommended to assist with maintaining cost recovery objectives as operational costs increase. Ambulance Service Fees set forth in Exhibit 1 will increase each July commencing July 1, 2022 by the annual change in the Consumer Price Index (CPI) -All Urban Customers, San Diego-Carlsbad (2020 = 303.932), as published by the United States Bureau of Labor Statics, subject to rounding to the nearest whole dollar. 4 of 29
February 15, 2022, Item #14Resources -An update to the City's fees will not change the way ambulance services are provided. No one is denied emergency services due to their type of healthcare coverage or ability to pay. The City offers payment plans with modest monthly payments and no interest or penalties. Additionally, there are resources for eligible uninsured individuals with Emergency Medi-Cal, California's state-funded health insurance benefits program, which may provide medical care in serious and sudden medical emergencies. In addition to these resources, staff are recommending the creation of a financial hardship assistance policy to allow the City Manager or designee authority to approve a reduction in fees for patients who are uninsured and are unable to pay for all or part of their bill due to limited income. The framework for this is included in the resolution. Environmental Review: This action is not subject to review under the California Environmental Quality Act (CEQA). Fiscal Impact: Utilizing the proposed fee schedule, the City could increase annual billing amounts and associated cost recovery from approximately $2,700,000 to $9,800,000 and result in additional estimated receipts of $1,800,000-$3,000,000 annually in FY22-23 compared to $1,193,957 million collected in FY20-21. A smaller revenue adjustment in the current fiscal year of $300,000 is estimated due to the timeframe to receive reimbursements from insurance providers. However, because the revenue estimates are gross averages and reimbursement is dependent upon the payer mix, number of transports, etc., the actual revenue could vary significantly changing the amount of cost recovery the City realizes. The amount of cost recovery to the City realizes will be better understood over time. Revenue is reflected in the Paramedics Division budget (503050). In order amend the fee schedule, it is necessary for the City Council to adopt a Resolution authorizing this action. Public Notification: A Notice of Public Hearing was published in the Poway News Chieftain on Thursday, January 27, 2022 and February 3, 2022. Attachments: A. Ambulance Rates Study January 27, 2022 B. Resolution Amending Existing and Establishing New Fees for Emergency Medical Services and Ambulance Transport Within the Fire Department Section of the Master Fee Schedule. Reviewed/ Approved By: Wend serman Assistant City Manager 5 of29 Reviewed By: Alan Fenstermacher City Attorney e City Manager
February 15, 2022, Item #14Prepared by: ~NBS helping communiti fund tomorrow nbsgov.com 6 of29 ATTACHMENT A Corporate Headquarters 32605 Temecula Parkway, Suite 100 Temecula, CA 92592 Toll free: 800.676.7516
February 15, 2022, Item #14TABLE OF CONTENTS 1. Executive Summary ........................................................................................................ 5 2. Project Approach ............................................................................................................ 7 2.1 Legal Foundation ....................................................................................................... 7 2.2 Project Approach ....................................................................................................... 8 3. Analysis ........................................................................................................................ 12 3.1 Cost of Service Analysis ........................................................................................... 12 3.2 Fee Establishment ................................................................................................... 17 3.3 Cost Recovery Evaluation ........................................................................................ 18 4. Conclusion .................................................................................................................... 22 7 of29
February 15, 2022, Item #141. EXECUTIVE SUMMARY The City of Poway wished to perform a study of its fees for ambulance services. The City's primary purposes in conducting this Study were to ensure that fees do not exceed the costs of providing services and to provide an opportunity for the City Council to set fee amounts according to local cost recovery policies. The body of this report illustrates calculation of the maximum fee amounts that reflect the City's full costs of providing services, as well as the policy options for considering implementation of fee amounts at or below that ceiling. This Study identified approximately $14.9 million in total annual City costs of providing Emergency Medical Services (EMS). The City bills $2.7 million, per year, on average, for ambulance services at current fee amounts. If the City were to collect 100% of their billings, revenue received would recover approximately 18% of the total annual costs of providing EMS services. However, review of historical EMS calls for service data showed that not all calls result in an ambulance transport and/or treatment without transport service. Of those calls that do result in an ambulance transport and/or treatment without transport service, there are instances when no bill for service occurs, such as mutual aid response where the City does not provide transport service. Additionally, most bills for ambulance services do not result in full payment. Depending on whether the recipient of a bill is a private or public insurance company, or individual, significant write downs, write offs, and payment delays typically occur. Based on an analysis of billing and revenue receipts data, the City's receives, on average, approximately 43% of the annually billed amount for services. As shown in Table 1 on the next page, at current annual billing activity levels, the City could increase "Average Annual Billings at Current Fees" from $2.7 million to the "100% Full Cost Recovery Fee Levels" of $9.8 million per year. The "Collected" row of the table considers that the average revenue received is 43% of annual billings due to write offs, etc. Therefore, the net increase in revenue received by increasing current fees to full cost recovery fee amounts is an estimated $3 million. As discussed in Section 2.2.3 of this report, there may be local policy considerations for adopting fees at less than the calculated full cost recovery amount. Also, the Centers for Medicare and Medicaid Services (CMS) sets limits, or "caps", for how much a provider can be reimbursed for administering ambulance services. CMS, however, does not regulate how much can be charged to individual patients or private insurance companies. All these considerations and nuances will impact the amount of revenue ultimately collected from any increase in ambulance fees for services. Per City staff's request, Section 3.3.1 of this report presents three cost recovery options for consideration: • Option 1: Transport fees established at 100% full cost recovery; Add-on charges assumed at no change from current fee amounts ONBS 8 of29 CITY OF POWAY Ambulance Rates Study 5
February 15, 2022, Item #14• Option 2: Transport fees and Add-on charges established at the average of the regional comparison • Option 3: Transport fees and Add-on charges at the 66th percentile of the regional comparison Table 1 shows a summary of annual estimated revenue projections for each of the policy options described. Billed Collected Net Col I ected Revenue Increase TABLE 1. REPORT SUMMARY Estimated Annual Billings per Policy Option 100% Full Cost Regional Fee Levels Regional Fee Levels Average Annual Billings at Current Fees Recovery Fee Levels -Average -66th Percentile $ 2,731,204 $ 9,754,207 $ 5,206,073 $ 6,771,947 $ 1,184,550 $ 4,169,923 $ 2,225,596 $ 2,895,007 $ 2,985,373 $ 1,041,046 $ 1,710,457 As shown, the potential net increase in revenue from increasing current fees to one of the presented policy options in this report is estimated at between $1 million and $3 million. However, predicting the amount to which adopted fee increases will truly affect City revenues is difficult, given that reimbursement rates for different types of fee payers ultimately drives what percentage of any bill for ambulance services is actually paid. ONBS 9 of29 CITY OF POWAY Ambulance Rates Study 6
February 15, 2022, Item #142. PROJECT APPROACH In approaching any fee study, we at NBS assess the unique conditions of the agency with which we work, apply a core philosophy, and select methodologies that best fit the requirements of the individual agency. Given the diversity and nuances present in many aspects of city finance and policy, this is a necessary strategy since one-size-fits-all methods are not sustainable once they become owned by the agency served. There is a legal foundation in place that provides the City with the authority to impose fees for the services it provides. The cost of providing these services and activities can be reasonably calculated and fees can be structured in a manner that allows the City to recover up to 100% of service costs. The calculation of the cost of providing services is an analytical effort that involves adopted and expected cost information and estimates of time (or time tracking information) required to perform a service or activity. Determining the targeted level of cost recovery from a new or increased fee is not an analytical exercise. It involves agency-specific judgments linked to a variety of factors, such as existing City policies, agency-wide or departmental revenue objectives, economic goals, community values, market conditions, level of demand, and others. Further, the Centers for Medicare and Medicaid Services (CMS) sets limits, or "caps", for how much a provider can be reimbursed for administering ambulance services. CMS, however, does not regulate how much can be charged to patients or private insurance companies. If the adopted fee is set at an amount that does not exceed the estimated and reasonable full cost of providing the service or activity requested, the City is in compliance with the legal framework currently in place. 2.1 Legal Foundation In California, there is great variability amongst fees charged to individuals for receiving ambulance transport and/or treatment. There is no set standard in California locally or statewide for how ambulance fees and rates should be calculated or administered. Therefore, in our opinion, the foundation for justification of ambulance fees for services needs to rely on a combination of federal guidelines and requirements as well as California state authorities for charging fees. CMS is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid. CMS develops a national Ambulance Fee Schedule for services eligible for partial reimbursement to providers. CMS sets limits, or "caps", for how much a provider can be reimbursed for administering ambulance services. CMS, however, does not regulate how much can be charged to patients or private insurance companies. For the ambulance transport benefit under Medicare Part B, an annual update is applied to the payment limits for ambulance transports that is equal to the percentage increase in the Consumer Price Index for All Urban Consumers (CPI-U) for the 12-month period ending with June of the previous year. This study relies on several of the CMS guidelines to structure which types of fees are charged for Medicare and Medicaid billing purposes. ONBS 10 of 29 CITY OF POWAY Ambulance Rates Study 7
February 15, 2022, Item #14It is generally accepted in California that cities are granted the authority to impose user and regulatory fees for services and activities they provide through provisions of the State Constitution. More specifically, the type of fees the City of Poway seeks to establish for ambulance services fall under the California Constitution Article XIII C. Section l(e), which provides seven stated exceptions to the State's definition of a "tax". The City's ambulance fees represent cost recovery opportunities entirely within the City's control. These are revenues which the City Council may, at its sole discretion upon public hearing, implement and/or modify without further public process or approval. The only legal limitation on the establishment of these fees is that they may not exceed the estimated and reasonable costs incurred to provide the service or perform the function for which the fee is charged. 2.2 Project Approach The fee study is a quantitative effort which compiles the full cost of providing governmental services and activities and translates those costs into proposed fee amounts best aligned with how services are provided. There were three phases of analysis completed during this study: 1. Cost of Service Analysis 2. Fee Establishment 3. Cost Recovery Evaluation 2.2.1 COST OF SERVICE ANALYSIS A Cost of Service Analysis is a quantitative effort that compiles the full cost of providing governmental services and activities. There are two primary types of costs considered: direct and indirect costs. Direct costs are those that specifically relate to an activity or service, including the real-time provision of the service. Indirect costs are those that support provision of services in general but cannot be directly or easily assigned to a singular activity or service. The following are different types of direct and indirect costs that are considered in the Cost of Service Analysis: Direct Costs: • Direct personnel costs -Salary, wages and benefits expenses for personnel specifically involved in the provision of services and activities to the public. • Direct non-personnel costs -Discrete expenses incurred by the City due to a specific service or activity performed, such as contractor costs, third-party charges, and very specific materials used in the service or activity. Indirect Costs: • Indirect personnel costs -Personnel expenses supporting the provision of services and activities. This can include line supervision and departmental management, administrative support within a department, and staff involved in technical support activities related to the direct services provided to the public. • Indirect non-personnel costs -Expenses other than labor involved in the provision of services. ONBS 11 of 29 In most cases, these costs are allocated across all services provided by a department, rather than directly assigned to individual fee categories. CITY OF POWAY Ambulance Rates Study 8
February 15, 2022, Item #14,, Overhead costs -These are expenses, both labor and non-labor, related to City-wide support services. Support services include general administrative services such as City Manager, Finance, Human Resources, etc. The amount of costs attributable to the City included in this Study were sourced from the City's Cost Allocation Plan prepared by the Finance Department. All cost components in this Study use annual (or annualized) figures, representing a twelve-month cycle of expenses incurred by the City in the provision of services. Once the total estimated annual costs of providing services are known, further analysis is completed to identify service costs that may not be eligible for recovery in the fees subject to study. To translate the annual costs of providing fee-related services into full cost-recovery individual fee amounts, we applied estimated or tracked time data and estimated or tracked activity data as an indicator of the level of service provided by type of service provided. 2.2.2 FEE ESTABLISHMENT The Study's process provided the opportunity to propose additions and deletions to the fee schedule, as well as to rename, reorganize, and clarify fees imposed. Many such revisions better conform fees to current practices, as well as improve the calculation offees owed by an individual, the application of said fees, and the collection of revenues. In most cases, the current structure of fees did not change; the focus is to recalibrate the fee amount to match the costs of services. In several cases, however, fee categories and fee names were simplified or re-structured to increase the likelihood of full cost recovery, or to enhance the fairness of how the fee applies to various types of fee payers. 2.2.3 COST RECOVERY EVALUATION The fee model compares the existing fee for each service or activity to the average total cost of service quantified through this analysis. A cost recovery rate of 0% identifies no current recovery of costs from fee revenues (or insufficient information available for evaluation). A rate of 100% means that the fee currently recovers the full cost of service. A rate between 0% and 100% indicates partial recovery of the full cost of service through fees. A rate greater than 100% means that the fee exceeded the full cost of service. Fees examined in this Study should not exceed the full cost of service. In other words, the cost recovery rate achieved by a fee should not be greater than 100%. We assist with modeling the "recommended" or "targeted" level of cost recovery for each fee, always established at 100%, or less, than the calculated ful I cost of service. As covered in section 2.1 Legal Foundation, while CMS sets limits, or "caps", for how much a provider can be reimbursed for administering ambulance services, the agency does not regulate how much can be charged to patients or private insurance companies. As such, targets and recommendations always reflect agency-specific judgments linked to a variety of factors, such as existing City policies, revenue objectives, economic goals, community values, market conditions, level of demand, and others. Because this element ONBS 12 of 29 CITY OF POWAY Ambulance Rates Study 9
February 15, 2022, Item #14of the Study is subjective, the results of this study provide the cost of service calculation based on 100% full cost recovery as well as the framework for the City to adjust in accordance with the City's goals as pertains to code compliance, cost recovery, economic development, and social values. 2.2.4 COMPARATIVE FEE SURVEY Often policy makers request a comparison of their jurisdiction's fees to surrounding or similar communities. City staff provided NBS with a 2019 survey of similar fees and charges in comparable agencies. The names of San Diego agencies surveyed have been marked as "Provider" for confidentiality. As illustrated in the comparison survey, the City's current Ambulance Transport fees are lower than most of the comparison agencies. The Treatment and Release fee is around the average of agencies that charge fees for assessment at the scene. The remaining fees such as EKG, Medications, Mileage, Night Charge, Supplies, and Oxygen fall in the middle of the other comparison agencies surveyed. While a comparison can provide a sense of the local market pricing for services and be useful in gauging the impact of recommendations for fee adjustments, the following should be noted about the general use of comparative survey data: • Comparative surveys typically do not provide information about the cost recovery policies or procedures inherent in each comparison agency. • A "market based" decision to price services below the full cost of service calculation, is the same as deciding to subsidize that service. • Comparative agencies may or may not base their fee amounts on the estimated and reasonable cost of providing services. • Comparative fee survey efforts are often non-conclusive for many fee categories. Comparison agencies typically use varied terminology for provision of similar services. The results of the Comparative Fee Survey for the City's Ambulance fees are shown on the following page. ONBS-13 of 29 CITY OF POWAY Ambulance Rates Study 10
February 15, 2022, Item #14~
ALS2 BLS Treat and Release -.i:a,. Units
0 .... Resident Non-Resident Resident Non-Resident Resident Non-Resident Resident Non-Resident
N !Provider 1 \Q
Provider 2 $4,451.94 $4,451.94 $3,967.94 $3,967.94 $1,613.83 $1,613.83
Provlder3 $3,883.21 $3,883.21 $3,425.37 $3,425.37 $1,487.05 $1,487.05
Provider4 $3,287.00 $3,287.00 $3,026.00 $3,026.00 $2,452.00 $2,452.00
Provider 5 $3,287.00 $3,287.00 $3,026.00 $3,026.00 $2,452.00 $2,452.00
Provlder6 $3,166.00 $3,166.00 $2,900.00 $2,900.00 $2,228.00 $2,228.00
id $3,166.00 $3,166.00 $2,900.00 $2,900.00 $2,228.00 $2,228.00
Providers $3,166.00 $3,166.00 $2,900.00 $2,900.00 $2,228.00 $2,228.00
Provider9 4 I $3,147.57 $3,147.57 $2,967.48 $2,967.48 $1,076.11 $1,076.11 $165.00 $165.00
rovider 10 $3,086.43 $3,086.43 $2,660.93 $2,660.93 $857.65 $857.65
rovider 11 2,787.00 $2,787.00 $2,526.00 $2,526.00 $2,207.00 $2,207.00
Provider 12 $2,671.34 $2,671.34 $2,396.98 $2,396.98 $2,022.71 $2,022.71 $202.74 $202.74
Provider13 $2,600.52 $2,600.52 $2,343.43 $2,343.43 $1,319.81 $1,319.81
Provlder14 $2,590.42 $2,590.42 $2,392.33 $2,392.33 $1,076.11 $1,076.11 $165.00 $165.00
Provider 15 $2,161.07 $2,161.07 $1,962.98 $1,962.98 $1,076.11 $1,076.11
Provider 16 $2,100.00 $2,100.00 $2,100.00 $2,100.00 $865.00 $865.00
Provider 17 $1,697.00 $1,829.00 $1,580.00 $1,709.00 $1,000.00 $1,117.00 $154.00 $204.00
Provider 18 $1,668.00 $1,668.00 $1,668.00 $1,668.00 $1,668.00 $1,668.00 $150.00 $150.00
Provider 19 $1,635.00 $1,824.00 $1,523.00 $1,712.00 $1,479.00 $1,668.00 $138.00 $200.00
Provider 20 $1,458.61 $1,458.61 $1,458.61 $1,558.61 $1,458.61 $1,458.61 $182.34
Provider 21 $1,330.11 $1,569.89 $1,308.41 $1,504.78 $475.41 $589.10
Provider 22 $1,320.00 $1,840.00 $1,180.00 $1,680.00 $980.00 $1,480.00 $100.00 $150.00
$1,268.75 $1,370.25 $1,167.25 $1,268.75 $952.33 $952.33 $203.00
$1,255.00 $1,255.00 $1,255.00 $1,255.00 $915.00 $915.00 $150.00 $150.00
Provider 25 $1,141.00 $1,141.00 $1,141.00 $1,141.00 $1,016.00 $1,016.00
Footnote 1'1: Provider 26 is City of Poway Ambulance
Mileage 02 Meds
3.77 $317.49
$63.87 $241.94
$60.39 $228.91
$48.00 $118.00
$48.00 $118.00
$48.00 $127.00
$48.00 $127.00
$48.00 $127.
$43.33 $156.54 I I
$39.90 $127.39
$48.00 $118.
$41.32 $33.65
$46.18 $203.17
$43.33 $156.54
$43.33 $156.54
$21.50 $100.00 $15.00
$27.00 $65.00 Cost+ 55%
$18.50 $80.00 Variable
$19.00 $94.00
$24.32 $91.18 Cost
$24.00 $73.38 $664.54
$34.80 $50.00 Cost+l00%
$23.25 $76.13
$24.00 $65.00 cost+
$25.00 $93.00 Variable
Add om • EKG
I I
$50.00 $85.00
Varies $20.00
$28.00
Res-Cost+ $50.00
90%Non-R
Cost plus
137%
Varies $33.96 I
$128.15 $36.17 I
Varies $20.00 I
Varies I I
Varies I $20.00 I
Varies
Night Charge
$155.09
$155.09
$30.00
$43.00
$43.41
$50.00
I
I
I
I
I
CPR Non-
Trans
$2,100.00
$621.13
$150.00
I
I
I
:r:t:too -
I $253.66
$125.00
$154.00 I $154.00
$100.00
$30.
$100.00
February 15, 2022, Item #142.2.5 DATA SOURCES The following data sources were provided by the City and used to support the cost of service analysis and fee establishment phases of this Study: • Adopted Budget for Fiscal Year (FY) 2021-22 • A complete list of the Fire Department's personnel, salary/wage rates, paid benefits, etc. • Prevailing fee schedules • Annual ambulance activity and billing data Calls for service data The City's adopted budget is the most significant source of information affecting cost of service results. We did not audit or validate the City's financial management and budget practices, nor was cost information adjusted to reflect different levels of service or any specific, targeted performance benchmarks. This Study has accepted the City's budget as a legislatively adopted directive describing the most appropriate and reasonable level of City spending. ONBS 15 of 29 CITY OF POWAY Ambulance Rates Study 11
February 15, 2022, Item #143. ANALYSIS The focus of this Study is on fees charged for ambulance services provided by the City. The following is a summarized list of fees studied: • ALS -Advanced Life Support includes emergency medical care performed for sustaining life, including cardiopulmonary resuscitation (CPR), defibrillation, airway management, and the administration of drugs and medications. Additional medical procedures may include cardiac monitoring, I.V.'s, and the use of diagnostic devices. • BLS -Basic Life Support generally does not include the administration of drugs or invasive skills. • Treatment and Release -Flat fee for services applied when the City responds to an emergency call for service, administers care at the scene, and does not transport the patient to hospital. • Related Add-Ons -Itemized charges allowed by CMS for EKG services, Oxygen, Fuel, Medications, and Night services. The fees examined in this Study excluded other fire related fees for services, development impact fees, utility rates, and any special tax assessments, all of which fall under distinct legal, analytical, and procedural requirements different from the body of user fees analyzed in this effort. Additionally, this Study fines and penalties imposed by the City for violations to its requirements or codes. 3.1 Cost of Service Analysis A full range of fire and paramedic services are provided by the City's Fire Department. These services can be summarized into three main service delivery programs for purposes of this analysis: • Fire Operations and Suppression Response -Emergency response related to fire incidents and other types of emergencies. • Emergency Medical Services (EMS) -Ambulance response services that typically result in a transport to a hospital or treatment on-scene without transport. • Fire Prevention -Annual inspections of commercial buildings, development review, Fire Code permits, investigative and code enforcement activities, etc. Personnel respond from three (3) strategically located fire stations to provide quick and effective response. 3.1.1 ANNUAL COST OF EMS SERVICES The focus of this cost of service analysis was to reasonably estimate the total annual costs of providing ambulance services that can be recovered through fees for services. Table 2 presents the total cost of service analysis for the City's Fire Department, segregated into the main service delivery programs: ONBS-16 of 29 CITY OF POWAY Ambulance Rates Study 12
February 15, 2022, Item #14TABLE 2. TOTAL FIRE DEPARTMENT SERVICE COSTS PER PROGRAM I E I General I I mergency Cost Element d" 15 . Operations/ Fire Prevention TOTAL Me 1ca erv1ces Labor Recurring Non-Labor Citywide Overhead Department Admi n $ 5,263,409 $ 334,438 7,988,282 1,276,295 Suppression 2,719,107 $ 1,188,132 3,898,360 733,266 503,856 $ 8,486,372 153,182 1,675,752 620,554 12,507,197 120,018 2,129,579 As shown, the total cost of providing all Department services is approximately $24.8 million. EMS services are approximately $14.9 million, which is 60% of total Department costs. EMS DIRECT LABOR COSTS The amount of "Labor" costs shown in Table 2 above was established as follows. Firefighters and paramedics are divided into 3 shifts working on a rotational schedule. Utilizing a constant staffing philosophy, each shift consists of 17 personnel ready to respond and provide emergency and non-emergency services any time of day. According to the calls for service report, most calls for service responded to by the Department are EMS rather than suppression related. As to how resources are deployed for EMS response, there are two (2) ambulances currently in service, seven (7) days per week, twenty-four (24) hours per day. Two (2) additional ambulances are kept ready in reserve to ensure adequate coverage for the community's needs. The two (2) ambulances in service are supported by three (3) paramedic fire engines and one (1) truck. Each time an ambulance responds to a call for service, a paramedic engine accompanies that ambulance to provide medically necessary support to the ambulance and personnel inside it. The City is dedicated to ensuring a paramedic is on scene within eight (8) minutes of a dispatched call, so an engine is always dispatched to a medical call along with ambulance. Each ambulance is staffed with two people, both are paramedic firefighters. Each paramedic engine is staffed with three people: a captain, an engineer, and a firefighter. All personnel on engines are paramedics. An analysis of calls for service for FY 2017 /18, FY 2018/19, and FY 2019/20 shows the breakdown of incidents and minutes for EMS calls versus other types of calls. CNBS 17 of 29 CITY OF POWAY Ambulance Rates Study 13
February 15, 2022, Item #14TABLE 3. TIME ON TASK . k ( 1 • 11 ) b f . Percentage of Time on Tas Tota Time on Ca s Num er o Minutes . Minutes Emergency Medical Response 559,007 82% Other Response Type 120,961 18% Table 3 shows the City's response time for Emergency Medical Services is approximately 82% of all calls for service. Because the City accounts for salaries and benefit expenses for all paramedic personnel in one central accounting/budgetary unit {Fire Suppression), a method for allocating direct labor costs between the Department's main service delivery programs is needed. To estimate the amount of salaries and benefit costs dedicated to EMS, the time on task split of 82% for personnel costs for Fire Captain/Paramedic and Firefighter/Paramedic positions are allocated to EMS, as are 18% of Fire Engineer/Paramedics position costs. OPERATING AND CAPITAL COSTS Review of the City's adopted expenditure budget for FY 2021/22 identified several on-going operating costs that are directly attributable the provision of EMS services. Unlike labor expenses, the City accounts for EMS related operating costs in a singular and separate accounting unit from Fire Suppression. These are shown in Table 2 as "recurring non-labor", and further detailed in Table 4, below: TABLE 4. EMS OPERATING COSTS Operating Cost Item FY 21/22 Budget Professional Develop & Recogn $ 250 Other Professional Fees 50,600 Utilities-Other 9,050 Hazardous Waste Removal 1,500 Vehicle Operations & Maintenance 57,330 Essential Training 8,900 Other Contractual Services 19,913 Equipment Repair & Maint. 19,700 Office & Stationery Supplies 700 Medical Supplies 37,345 Safety Supplies 5,500 Operating Supplies 4,500 Printing 1,650 Publication & Dues 50 Capital Outlay Rental-Vehicle 81,450 Cap Outlay Rental-Other Equip. 36,000 -~ En,\f,'£f:1 l-ll.'~l lt•J.ir:.11 Approximately $334,000 are operating costs directly dedicated to providing Emergency Medical Services. Operating costs include services and supplies needed to support operations, as well as the amortized cost of replacing vehicles and equipment needed for service delivery which are shown as the "capital outlay" expenditures at the bottom of the list. ONBS-1s of 29 CITY OF POWAY Ambulance Rates Study 14
February 15, 2022, Item #14OVERHEAD COSTS There are two types of overhead costs considered in this analysis: Citywide overhead and Fire Department overhead. Citywide Overhead costs include administrative services that support the Fire Department such as Finance, Human Resources, City Manager, Information Technology, etc. The City's Finance Department completes an overhead cost allocation plan analysis, which for FY 21-22 identifies $13.5 million in overhead costs attributable to the Fire Department. TABLES. OVERHEAD COSTS I 2021-22 Allocated Indirect/Support Services Ad d 8 d opte u get Citywide Overhead Safety Services -Fi re Suppression $ 12,317,738 Safety Services -Fire Prevention Safety Services -Paramedics 667,905 475,918 The total share of these costs attributable to EMS services, is shown in Table 6. TABLE 6. EMS OVERHEAD COSTS I Emergency Allocated Indirect/Support Services Medical Citywide Overhead Safety Services -Fire Suppression Safety Services -Fi re Pr even ti on Safety.Services -Paramedics Services 7,546,105 442,177 The portion of overhead costs allocated to EMS, is based on the overall share of Department staff time spent on EMS, resulting in approximately $8 million of overhead costs. Fire Department Administration Costs were also allocated to all main service areas, with EMS receiving approximately $1.3 million, as shown in Table 2. ONBS 19 of 29 CITY OF POWAY Ambulance Rates Study 15
February 15, 2022, Item #14TOTAL ANNUAL COST ALLOCATION SUMMARY Based on the analysis competed for each attributable cost component described above, Table 7 summarizes the City's total estimated annual cost of providing EMS services at $14.9 million. As described above, the total estimated cost of providing services includes all identifiable direct and indirect costs. TABLE 7. TOTAL ANNUAL EMS COSTS I Emergency Cost Element d. 1 S . Me 1ca erv1ces Labor Recurring Non-Labor Citywide Overhead Department Ad min 3.1.2 INDIVIDUAL FEE FOR SERVICE COSTS $ 5,263,409 334,438 7,988,282 1,276,295 To translate the total annual EMS costs established in Table 7 into individual costs per type of ambulance service, EMS costs were allocated to individual fee for service categories based on the average number of calls by type and the average amount of time required to service each type of call. Both calls by type and average time per call were sourced from the Fire Department's dispatch records Utilizing calls for service data provided by the City's dispatch system, a weighted distribution factor was derived by call volume and call time between Transports, Non-Transports, and Other Calls. Each time an ambulance responds to a call for service, a paramedic engine accompanies that ambulance to provide medically necessary support to the ambulance and personnel inside it. Therefore, service time must reflect the total number of personnel responding to each call, on average: • Two person ambulance -Paramedic/Firefighters • Three person paramedic Engine -Captain, Engineer and Firefighter. Each of these people are also Paramedics. • Transports are defined as calls that consisted of a patient being transported to the hospital by ambulance. Transports last an average of approximately 60 minutes per call. • Non-Transports are defined as calls where treatment was administered on the scene, but the ambulance did not transport the patient to a hospital, also known as "Dry Run". Based on conversations with City staff, if the medic unit is on the scene for more than 25 minutes, it would be indicative that an assessment with some form of treatment or advanced evaluation was performed. ONBS-20 of 29 CITY OF POWAY Ambulance Rates Study 16
February 15, 2022, Item #14• Other Calls are defined as calls that last less than the 10-minute "on-scene time" threshold, which would be indicative of no treatment was administered on-scene and no transport was provided by ambulance. These calls have no potential for recovery of costs through fees for ambulance services. The cost of service analysis for individual ambulance services is shown in Table 8 below. TABLE 8. AVERAGE TOTAL COST PER TYPE OF AMBULANCE SERVICE Average Average Average Average Average Service Service Average Type of Ambulance Service Time Service % Annual Time Time Cost per Service (hrs)-time(hrs) -Distribution Calls Ambulance (hrs) -(hrs)-Annual Service Engine Total Transport 2,851 1.98 2.97 2.47 7,049 86% $ 4,369 Non-Transports 684 0.58 0.87 1.44 988 12% $ 2,550 Other Calls 260 0.20 0.30 0.49 128 2% $ 870 Total 3,795 2.75 4.13 4.41 8,165 100% $ 3,801 Per the dispatch data, Table 8 shows the average annual distribution of effort required to service various types of Emergency Medical Services calls as 86% Transports, 12% Treatment Non-Transports, and 2% Other Calls. Applying the $14.9 million of costs shown in Table 7, the average cost of service per ambulance call is $3,801, and for each type of ambulance service is $4,369 for Transport, $2,550 for Treatment Non-Transports, and $870 for Other Calls. 3.2 Fee Establishment The City's current fee structure and fee amounts are shown in Table 9 on the following page. As discussed in Section 2.2.2 of this report, the Study's process provided the opportunity to propose additions and deletions to the fee schedule, as well as to rename, reorganize, and clarify fees imposed. In general, ambulance fee schedules tend to be standardized across local governments. Fee schedules typically contain the following types of fees for services: • Transport Fees, which are typically delineated between ALS versus BLS transport services, and treatment without transport services. Fees for transport services also sometimes indicate different fee amounts for residents versus non-residents. • Add-on Charges, for services provided during transport that vary per incident, such as mileage, oxygen, medications, supplies, EKG, etc. Poway's transport fees are structured within the same standards seen in other agencies. However, the City's official Master Fee Schedule adopted by Resolution 08-083 lists only two Add-on charges for Mileage and Oxygen. As shown in Table 9, and in the regional comparison of fees, the Study identified other active Add-on charges in the City's billing data. NBS recommends the City publish all standard Add-on charges that it intends to bill for on a routine basis in the Master Fee Schedule. ONBS 21 of 29 CITY OF POWAY Ambulance Rates Study 17
February 15, 2022, Item #143.3 Cost Recovery Evaluation Table 9 shows the Total Cost of Service Per Activity calculated by the Study (full cost recovery fee amounts} as compared to the current fees charged by the City. TABLE 9. CURRENT FEE EVALUATION AND PERFORMANCE Fee Description EMERGENCY MEDICAL SERVICES and AMBULANCE TRANSPORT Base Charge-Advanced Life Support 1 Poway Resident Non-Resident Base Charge-Advanced Life Support 2 Poway Resident Non-Resident Base Charge-Basic Life Support Poway Resident Non-Resident Treatment and Release ADD-ON CHARGES Per-Mi I e Charge Oxygen Medications Sup lies EKG Fee Unit / Total Cost of Type Service Per Poway Current Fee Activity flat $ 4,369 $ 1,029 fl at $ 4,369 $ 1,366 flat $ 4,369 $ 1,029 fl at $ 4,369 $ 1,366 flat $ 4,369 $ 866 flat $ 4,369 $ 1,196 flat $ 2,550 $ 150 per mile $ 16 fl at $ 66 flat Cost lus 50% flat $ 49 flat Existing Cost Recovery % 24% 31% 24% 31% 20% 27% 6% $ 46 -------.. ································· ·······························+~---~~·....;...----+--.. Night Charge (7pm to 7am) flat $ --···················?..9. .......... ----CP_R_N_o_n_-T_ra_~~ .................................................................... ....__fl_a t--+-------1-'$'-----+-------4 Extra Attendant __ f_l a_t_-1-······································+-'-$ ___ __.. ___ -1 As shown, the Poway's current transport fees recover between 6% and 31% of the total cost of providing each service. Add-on charges were not evaluated on a cost-per-service basis; however, by excluding the anticipated billings associated with these charges from the calculation of the transport rates, the risk of overcharging a recipient for transport service is mitigated. 3.3.1 RECOMMENDED FEES -POLICY APPROACH The following table shows three options for establishing ALS Transport, BLS Transport, and Treatment and Release (Non-Transport} fees either at or below the 100% full cost of service fee amounts calculated through this Study. • Option 1: Transport fees established at 100% full cost recovery; Add-on charges assumed at no change from current fee amounts ONBS-22 of 29 CITY OF POWAY Ambulance Rates Study 18
February 15, 2022, Item #14• Option 2: Transport fees and Add-on charges established at the average of the regional comparison • Option 3: Transport fees and Add-on charges at the 66th percentile of the regional comparison TABLE 10. POLICY OPTIONS OPTION 1 OPTION 2 OPTION 3 CURRENT Total Cost of Cost Cost Regional Fee Cost Existing Fee Fee Description Fee Unit/ Service Per Recovery Regional Fee -Recovery -66th Recovery Poway Cost No. Type Activity % Average % Percentile % Current Fee Recovery % EMERGENCY MEDICAL SERVICES and 1 AMBULANCE TRANSPORT Base Charge-Advanced Life Support 1 Poway Resident flat $ 4,369 100% $ 2,267 52% $ 2,900 66% $ 1,029 24% Non-Resident flat $ 4,369 100% $ 2,327 53% $ 2,900 66% $ 1,366 31% Base Cha rge-Adva need Life Support 2 Powa Resident flat $ 4,369 100% $ 2,461 56% $ 3,166 72% $ 1,029 24% Non-Resident flat $ 4,369 100% $ 2,520 58% $ 3,166 72% $ 1,366 31% Base Charge-Basic Life Support Powa Resident flat $ 4,369 100% $ 1,464 34% $ 2,228 51% $ 866 20% Non-Resident flat $ 4,369 100% $ 1,512 35% $ 2,228 51% $ 1,196 27% Treatment and Release flat $ 2,550 100% $ 153 6% $ 172 7% $ 150 6% 2 ADD-ON CHARGES Per-Mile Char e per mile $ 39 $ 48 $ 16 Oxygen flat $ 123 $ 127 $ 66 Medications flat Cost pl us 50% Cost pl us 50% Cost plus 50% Su lies flat $ 69 $ 69 $ 49 EKG flat $ 39 $ 68 $ 46 Night Char e (7pm to 7am) flat $ 75 $ 155 $ 50 CPR Non-Trans flat -·-----·-· __ $ ___ , ...... 957 ---····· ... $ 2,100 $ 100 Extra Attendant flat $ 102 $ 140 $ 50 Using this approach to establish recommended fees for the Council's consideration, the annual estimated billings for each policy option are illustrated in Table 11. Billed Collected Net Col I ected Revenue Increase TABLE 11. BILLED VS COLLECTED Estimated Annual Billings per Policy Option Average Annual Billings at Current Recovery Fee Levels 100% Full Cost Fees Regional Fee levels Regional Fee Levels -Average -66th Percentile $ 2,731,204 $ 9,754,207 $ 5,206,073 $ 6,771,947 $ 1,184,550 $ 4,169,923 $ 2,225,596 $ 2,895,007 $ 2,985,373 $ 1,041,046 $ 1,710,457 At current billing activity levels, the City could increase annual billing amounts from approximately $2.7 million at current fees, to up to $9.8 million at full cost recovery fee amounts. Once the collections rate of 43% is applied, the net increase in revenue collected ranges from an estimated $1 million to $3 million, ONBS-23 of 29 CITY OF POWAY Ambulance Rates Study 19
February 15, 2022, Item #14depending on the policy option chosen. However, as discussed further in Section 3.3.2, predicting the amount to which any adopted fee increases will affect City revenues is difficult to quantify. 3.3.2 PAYER MIX Understanding the City's payer mix is an important consideration when setting final fee amounts because most bills for ambulance services do not result in full payment. For example, as discussed throughout this report, CMS sets limits, or "caps", for how much a provider can be reimbursed for ambulance services. CMS, however, does not regulate how much can be charged to private paying patients or commercial insurance companies. Individuals may have issues with their ability to pay the full fee amount, and commercial insurance companies may have their own limits and reimbursement policies. Actual reimbursements are based upon billing the patient for the medical service provided and dependent on whether the recipient of a bill has private or public insurance, or no insurance. There are four basic categories of reimbursements. • Medicare -Primary health care coverage for people over the age of 65 • Medi-Cal -Component of the federal Medicaid program that is provided for qualified individuals and families • Commercial Insurance -Benefits purchased independently, or provided by employers to employees • Private Pay-For those without any form of medical insurance The data in the following tables shows the City's current payer mix based on financial class data and revenues reported by the City's third-party biller, Wittman Enterprises LLC. This information may be useful in understanding the impact on actual reimbursements received after recommended fees are adopted. TABLE 12. PAYER MIX -NUMBER OF TRANSPORTS Number of Percentage of Category Transports Transports Medicare 793 45.06% Medi-Cal 167 9.49% Commercial Insurance 192 10.91% Private Pay 608 34.55% Totals 1,760 100.00°/4 In Table 12, out of a total of 1,760 transports for FY 2019-20, Medicare is the largest category, representing 793 transports and 45.06% of the transports mix. Private Pay is the second largest, and Commercial Insurance and Medi-Cal categories are third and fourth largest. Table 13 shows the City's total revenues received by reimbursement category (payer mix) in FY 2019-20. As shown, Commercial Insurance payers have the highest reimbursement rate, followed by Medi-Cal, Medicare, and Private Pay. ONBS 24 of 29 CITY OF POWAY Ambulance Rates Study 20
February 15, 2022, Item #14TABLE 13. PAYER MIX -TOTAL REVENUE Number of Collection Percentage of Category Revenue Transports Rate Revenue Medicare 793 $ 525 $ 416,685 33.01% Medi-Cal 167 $ 893 $ 149,104 11.81% Commercial Insurance 192 $ 2,832 $ 543,817 43.08% Private Pay 608 $ 251 $ 152,838 12.11% Totals 1,760 $ 1,262,444 It is important to note that increasing ambulance transport fees and add-on charges does not necessarily translate to a total increase in revenues at the reimbursement/payor level. For example, due to the fee limits set by CMS, one should not expect the Collection Rate per transport to increase significantly from what is shown in Table 13. The same is likely true for Medi-Cal and Private Pay. Out of all four payer categories, Commercial Insurance is the most likely to pay the highest reimbursement rate and the most likely to exhibit flexibility in its Collection Rate as compared to the other categories. ONBS-2s of 29 CITY OF POWAY Ambulance Rates Study 21
February 15, 2022, Item #144. CONCLUSION Based on the Cost of Service Analysis, Fee Establishment, and Cost Recovery Evaluation outcomes presented in this Study, the proposed schedule of fees for City Council's consideration has been included in the City's accompanying Staff Report. As discussed throughout this report, the proposed fee schedule intends to improve the City's recovery of costs incurred to provide individual services, as well as to adjust fees downward where fees charged exceed the average costs incurred. Predicting the amount to which any adopted fee increases will affect City revenues is difficult to quantify. For the near-term, the City should not count on increased revenues to meet any specific expenditure plan. Experience with the revised fee amounts should be gained first before revenue projections are revised. However, unless there is some significant, long-term change in activity levels at the City, proposed fee amendments should enhance the City's cost recovery performance, over time, providing it the ability to stretch other resources further for the benefit of the public at large. Disclaimer: In preparing this report and the opinions and recommendations included herein, we relied on several principal assumptions and considerations regarding financial matters, conditions and events that may occur in the future. This information and assumptions, including the City's budgets, time estimate data, and workload information from City staff, were provided by sources we believe to be reliable; however, we did not independently verify such information and assumptions. While we believe our use of such information and assumptions is reasonable for the purpose of this report, some assumptions will invariably not materialize as stated herein and may vary significantly due to unanticipated events and circumstances. Therefore, the actual results can be expected to vary from those projected to the extent that actual future conditions differ from those assumed by us or provided to us by others. ONBS-26 of 29 CITY OF POWAY Ambulance Rates Study 22
February 15, 2022, Item #14RESOLUTION NO. 22-A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF POWAY, CALIFORNIA, AMENDING AND ESTABLISHING EMERGENCY MEDICAL SERVICES AND AMBULANCE TRANSPORT FEES WITHIN THE FIRE DEPARTMENT SECTION OF THE MASTER FEE SCHEDULE WHEREAS, California Government Code section 66016 et seq. establishes procedures for the adoption of fees for services by local government; WHEREAS, the City of Poway provides emergency medical services and ambulance transport as part of the operation of the fire department to residents and non-residents of Poway; WHEREAS, on May 4, 2010, the City Council adopted Resolution No. 10-017, adopting a Master Schedule of Fees; WHEREAS, a cost study and analysis of the current fee schedule indicates that an increase in the existing fees and establishing certain new fees is warranted; WHEREAS, the proposed fees do not exceed the reasonable costs of providing the services for which the fees are imposed; WHEREAS, the proposed fees will supersede any previously established fee for the City emergency medical services and ambulance transport; and WHEREAS, the City Council of the City of Poway held a duly noticed public hearing on January 18, 2022, allowing for the public to comment on the establishment of said fees. NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of Poway as follows: Section 1: The City Council finds that this amendment to the Master Fee Schedule is exempt from the requirements of CEQA pursuant to CEQA guidelines Section 15273 (a) (1 ). Section 2: The City's Master Fee Schedule is hereby updated to amend and establish fees for Emergency Medical Services and Ambulance Transport Fees of the Fire Department set forth in Attachment attached hereto this Resolution and are hereby approved and effective March 1, 2022. Section 3: Emergency Medical Services and Ambulance Transport Fees set forth in Attachment A will increase each July by the annual change in the Consumer Price Index (CPI) -All Urban Customers, San Diego-Carlsbad (2021 = 319.761), as published by the United States Bureau of Labor Statics, subject to rounding to the nearest whole dollar commencing July 1, 2022. Section 4: The proposed fees set forth in Exhibit 1 are based on costs incurred by the City in providing services, which the City Council finds to be reasonable. 27 of 29 ATTACHMENT B
February 15, 2022, Item #14Resolution No. 22-Page 2 Section 5: The City Manager, Fire Chief or staff designee may authorize a reduction in fees for individuals transported that do not have health insurance and a financial hardship is demonstrated or other extenuating circumstances. The determination of a financial hardship shall be based on 80% of Area Median Income (AMI) as determined for San Diego County published each year by the County of San Diego, Department of Housing and Community Development Services. Section 6: This Resolution shall become effective immediately. PASSED, ADOPTED AND APPROVED at a Regular Meeting of the City Council of the City of Poway, California at a regular meeting this 15th day of February, 2022, by the following vote, to wit: AYES: NOES: ABSENT: DISQUALIFIED: Steve Vaus, Mayor ATTEST: Carrie Gallagher, City Clerk 28 of 29
February 15, 2022, Item #14Exhibit 1 Resolution No. 22-Page 3 Emergency and Medical Services and Ambulance Transport Fees to be Amended and Established in the Fire Department Section of the Master Fee Schedule City of Poway Master Fee Schedule Fire Department Service Description Fee Fees subject to CPI adjustment annually July 1 each year. *Medications updated no less than annually based on costs. Emergency Medical Services and Ambulance Transport Base Charge-Advanced Life Support 1 $4,369 Resident/Non-Resident Base Charge-Advanced Life Support 2 $4,369 Resident/Non-Resident Base Charge-Basic Life Support $4,369 Resident/Non-Resident Treatment and Release $2,550 Resident/Non-Resident IAdd-Ons Per-Mile Charge $ 16 Oxygen $ 66 Medications* Cost Pl us 50% Supplies $ 49 EKG $ 46 Night Charge (7pm to 7am) $ 50 CPR Non-Transport $ 100 Extra Attendant $ 50 29 of 29