ORDER-2019-93 : Amend Melrose Revised Ordinances, Chapter 24, Article II - Fire Department, Sec. 24-32(E) - Emergency Rescue Vehicle, to set fees for FY 20.

Transcript (~33 min @ 2:07:40)

Speakers identified by voice; unnamed voices are numbered within this recording. Auto-caption text — verify against the video.

▶ 2:07:27 Speaker 1: Motion to move the bottom line of $4,808,586.48. Second. I have a motion to move the bottom line for this department. May the Alderman Medeiros, seconded by Vice Chair Boycelle. Any further discussion? All in favor? Aye. Opposed? Thank you. That will be recommended to the full board. I think that takes us to order number five.

▶ 2:07:49 Kate Lipper-Garabedian: Order 2019-94, Ambulance Enterprise Fund Budget for Fiscal 2020 in the amount of $939,684.03.

▶ 2:08:13 Monica C. Medeiros: Motion to take concurrent action along with order number 2019-93, amend Melrose-Lavias Ordinances, Chapter 24, Article 2, Fire Department, Section 24-32E, Emergency Rescue Vehicle, to set fees for FY20.

▶ 2:08:26 Kate Lipper-Garabedian: We have a motion to join, is that right, join the orders listed in number 5 and number 6 on our agenda tonight so that we can discuss them together. Seconded by Vice Chair Boisselle. All in favor? Aye. Any opposed? Okay, so we're now discussing both agenda item number five and six.

▶ 2:08:57 Speaker 1: May we have Mr. Mergenthal to come up as well to speak on rates?

▶ 2:09:06 Monica C. Medeiros: Perhaps first, well, I'm not sure which one of you might be able, if I still have the floor. Sure, go ahead, Alderman Harris. just sort of discuss the number of calls and just kind of the overall budget

▶ 2:09:29 Speaker 3: it's great to be back sorry I missed last year actually I think I I was sick last year but here I am again and I'm happy to say that you guys are nothing if not consistent your your call volume has stayed very consistent between 1500 to 1600 transports revenue has actual cash from annual service has been pretty

▶ 2:09:59 Speaker 3: consistent around 950 and you know as you all know every year there's a lot of thought that goes into it there's even been years where rates have been held level and I'm happy to say this is one of the more knowledgeable and

▶ 2:10:16 Speaker 3: responsible bodies that we see in terms of the thought that you put into your budget and and your rate setting there's a small increase and not to be redundant

▶ 2:10:34 Speaker 3: from the past years but I'll put it out there it's really pretty much a two-pronged analysis it's it's basically taking your cost of running the service and then we basically use your historical data which at this point now we've got some pretty good data about eight years worth and like I said it's remain pretty consistent. We're then able to project numbers in, payer mix, payer mix by payer mix, I mean, the mix of between patients who have Medicare, Medicaid, commercial insurance, and then folks with no insurance, and kind of plug those numbers in and have a projection, which I think is the chart that you guys have in front of you. And that's the same chart we've used for lo these many years and while I always give the disclaimer in caution it's not an exact science we've always been kind of in the neighborhood and we've always tried to be pretty conservative and in how we break it out over time you've got the same challenges as everyone else in health care when it comes to the billing higher deductible plans are certainly an impact on the billing side we actually about two years ago we actually implemented a new service we actually use it even for our ambulance service and in Cambridge also then in all the towns that we bill for where we have a an entity a third party actually takes a look at all of the insurances that we submit to them and see if there are deductibles and for patients who have deductibles we actually are able to hold the claim until and we set up a period of I think let's say it's about 70 days and usually by the time that goes oftentimes the hospital has hit the deductible or something else and then the ambulance services is better able and it makes sense too because frankly the you know the hospital bills make the ambulance bills pale in comparison and and ambulance is historically the the first bill that comes in based on the time of service so ambulance service is often disproportionately hit and the patient is disproportionately hit in appearances wise by the ambulance deductible and this has helped alleviate that for us and all the cities and towns that we bill for the other the other piece is certainly the replacement of commercial insurance by connector programs oftentimes that will result in patients where the reimbursement be much higher in a commercial plan to being closer to the Medicaid reimbursement level having a couple of those patients can can swing your bottom line having some of those deductibles can swing your bottom line but so far so good like I said we've got eight years of data on you folks all the data and the projection here is based on the historical payer mixes that we've seen over the recent years so year over year we feel pretty confident with where you're gonna land but again you know it's not a credit card you do not necessarily know what your call volume is going to be or what your pair mix is going to be but we all do the best to make the best estimate and I

▶ 2:14:21 Monica C. Medeiros: know we actually have some new members here since probably the last time you've been back so actually could you just explain your your title and sure so way

▶ 2:14:35 Speaker 3: back when when the world was young and the ambulance was reinstituted here in Melrose chief O'Brien at the time and Patrick asked me to come in and and take a look at the how we would reestablish billing it was one of the things that was one of the biggest obstacles in in the ambulance that was previously run and I think in combination with being able to get the manpower and the being able to go to the paramedic level getting a better handle on the billing everybody worked together including many of the folks in this room to reestablish the ambulance and bring it back in-house again and hey certainly there was you know the first year yeah you can end up throwing some darts in terms of what you think the payer mix will be and what you think the volume will be but thankfully we had some some good historical data from from your partner Cataldo ambulance who is you know they've they've always been an important player here too and the data from them was very helpful and we're able to be in the neighborhood and show how and it's proven out now over boy now I think nine years now that the service is sustainable and it's worked out well well we I I'm the CEO of pro EMS in Cambridge and so we do 9-1-1 in the city of Cambridge we also do paramedic intercept service out along route 2 and Emerson Hospital and we now bill for I want to say approximately 35 cities and towns in Metro Boston from all the way up to oh gee as far north as the New Hampshire border all the way down to Cape Cod now the other thing is is that we also do other services that we incorporate in because I now and again get a chance to emphasize and put my paramedic hat on and Melrose was a big part of that so Melrose is we have also a pretty robust training function at our place we have two large classes of paramedic paramedics every year I think several of our graduates and even some of our field staff have landed in Melrose over time and the Melrose paramedics regularly come to Cambridge we have a we have a large simulation lab with lifelike mannequins and instructors that Melrose has always availed themselves of in terms of keeping their medical and paramedic skills sharp that's critically important where you know you those are skills that go rusty on you and you need that kind of training and Melrose is right up to speed in keeping that up the other thing that we do is we do patient satisfaction surveys and those are things that you get you folks have seen in the past and Melrose has always been well above the the benchmark and we send a patient satisfaction survey to every single patient everyone that's transported and even patients who are not transported where we have data and a name and address and a way to mail them satisfaction survey last year I just I had a chance to check the numbers before came tonight and last year Melrose actually had about 300 surveys returned from patients with a satisfaction rate of over 95% so it's a lot of times it's it's not just kind of the blood and guts and the rescue type stuff a lot of times it's how the folks in the street work with the residents work with the patients and you know a lot of it is is being able to connect with a patient and being someone that's that's there in a what's always a difficult time and result results like that from such a large portion of people sending sending back comments and sending back scores I think speaks volumes for what your

▶ 2:18:56 Monica C. Medeiros: department is doing here and in this chart just so everybody can really understand it so it's broken down into types of payers medic Medicare Medicaid insurance and bill patients so that's the percentage that we're looking at of

▶ 2:19:13 Speaker 3: each of our payer mix and how that's exactly right and you can see the dramatic difference in and and so some of the metrics we would use are the prime metric that we use is net revenue per transport how much actual dollars you bring in on average for every time someone goes to the hospital and if you look at the numbers you can see it's very dramatic in that the commercial payers could make up almost two-thirds of your revenue and ultimately only account for 20 or 25 percent of the patients transported and that is the the constant struggle in health care that paradigm that cost to shift where Medicare and Medicaid are paying so far below what it costs to provide the service and so you know it's that it's that classic conundrum and health care problem that we all have of the of the $10 aspirin it's it's now it's a $20 aspirin at this point but you know one person is has Medicaid so maybe it's only paying two dollars for the aspirin and Medicare is paying three and commercial insurance is paying ten and someone who would no insurance whatsoever is paying zero and that all has to go in and balance out the other piece is that since the inception of the ambulance and and many of the other towns follow the same policy you have all always endorsed having the most humane collection policy possible and that's something that I think has worked well for for this community and many others we serve ambulance rates can be a shock to some folks when they get that bill however this body and many others that we work with are all consistent in how patients are treated very humanely and many bills are written off as financial hardship the last thing that we would ever want to do is have someone be discouraged from calling 9-1-1 for fear of the for fear of the of the bill and again this body for many years has been very supportive of that policy and I think it's worked well thank you and

▶ 2:21:42 Monica C. Medeiros: so just I think it's important to note that between Medicare and Medicaid Medicaid, that's 74% of our payer mix. And so they're generally not paying the full price of an ambulance, right? So people say, how on earth can this cost so much to go such a short amount of time? And that's definitely part of the mix. Are you aware of, I know there's been some discussion at the state level that may, I mean, I think it's really important that we set these rates here it's something that's not really our normal business but at the same time in the municipality our goal is to pay the cost and not overcharge people and always to find that balance I know there's some efforts at the state level to sort of fix the rates and I think that's a little bit dangerous because we might not be able to pay our costs and at the same time we don't all

▶ 2:22:42 Speaker 3: want to collect more than what we should it's a tremendous issue going on right now it's been a pretty much a constant battle for for probably going on seven or eight years now on Beacon Hill and folks have all banded together the Mass Municipal Association the fire chiefs of Massachusetts the PFFM Mass Ambulance Association, Mass Municipal Association and the fire chiefs and the PFM are very much leading the way now up on Beacon Hill to try to find legislation that sort of cuts it down the middle but you know at the same time eliminates surprise billing. That's something that we've always worked on and always always had as a goal which you know is certainly everyone is there's constant downward pressure in the rates. Those rates that you see in front of you, Medicare, that's pretty much, and I'm not talking about adjusted for inflation. I am talking about dollar for dollar. That's about the same reimbursement that you got about, I want to say, 11 years now the Medicaid rate is exactly the same since 2008 so as you can imagine the costs have gone up in the last 10 years but the government reimbursement has not historically Medicare is only reimbursing somewhere around half to 60 percent of the cost of an ambulance service Medicaid is probably is bouncing somewhere around 35 percent of the actual cost of transporting someone to the hospital and so that that is where that comes into play and it's absolutely critical that everybody work together to make Beacon Hill aware and and now Capitol Hill aware that EMS is different it's locally controlled and and EMS doesn't have a waiting room it's it's harder to control costs when you when you don't have a waiting room that's for sure and it it is different and you know when we're up there talking to folks we you know we say well and this is gonna be odd but we're actually going to tell you that we're different you know and everyone kind of cracks up but we actually are it is different and and we think we can show that and we've gotten some very good support up there but it's a it's a constant battle and we hope that you guys will always be there and with your folks at the MMA also and you have been but we all need to keep going forward and and working on this issue and I'm not sure if you or chief could

▶ 2:25:36 Monica C. Medeiros: talk about our response times and what what's our average response time our

▶ 2:25:43 Speaker 7: Our average response time is possibly three minutes, once we're out the door.

▶ 2:25:49 Monica C. Medeiros: Do you attribute that to some degree to having three stations?

▶ 2:25:55 Speaker 7: Well, that goes without speaking. If everybody's in where they're supposed to be, Engine 3 has the farthest response to, say, Penny Hill Road, that section of the city, Broadway for sure. So you're looking at some five-minute responses just to those areas alone.

▶ 2:26:16 Monica C. Medeiros: And that's from Engine 3?

▶ 2:26:18 Speaker 7: That's from the east side, from the commons, yeah.

▶ 2:26:22 Monica C. Medeiros: Is there any particular line items that you'd like to address here, Chief?

▶ 2:26:30 Speaker 7: No, the ones that were increased were all serviced.

▶ 2:26:37 Monica C. Medeiros: And we talk about some of the capital and the other line items.

▶ 2:26:46 Speaker 1: Now, this is an enterprise account, so the ambulance is paid, the capital expense is paid out of this.

▶ 2:26:49 Speaker 7: Rita.

▶ 2:26:51 Monica C. Medeiros: Okay. Thank you very much. I think the, oh, and sorry, could you just talk real quick about the proposed change in the per mile rate from $42 to $45 per mile? Is there anything of the mix that's in that?

▶ 2:27:08 Speaker 3: No, not really. mean the it's it's kind of a standard increase and for you folks mileage is a very very low line item um we have some towns where the average transport distance could be as long as much as 15 miles and for you guys the average is is closer to two um it's one of the benefits of the relationship that you have with melrose wakefield hospital and having a community hospital right here in your city it's a it's a it's a big difference in terms of uh the partnership you guys have with them i believe they're your medical control um as well as at the um as having a community hospital right in the city we're in cambridge we have a similar situation we have two in the city and it makes a huge difference in terms of being able to have units available and

▶ 2:27:56 Monica C. Medeiros: stay within the community actually i have one last question for you uh just do you have any suggestions for us since we're talking about uh you know trying to fill vacancies and recruitment

▶ 2:28:09 Speaker 3: do you have any recruitment suggestions i i gotta tell you the um the the recruitment and retention problem exists not just i mean back in the day you would you would see it a little more in the ambulance in ems and now that that has actually um entered into the fire service and the police There is a tremendous recruitment problem, and everyone is all sort of at a loss on how to try to fix it. For lack of a better analogy, a lot of people are throwing spaghetti against the wall to see if they can do something, but we're all doing stuff with, you know, so for us, for example, our EMTs, they enter, they start working a pro as an entry level EMT. not hiring to be emts we're hiring them when they suggest that they want to be a paramedic want to be a physician's assistant want to go on and we have that luxury of putting them right into our paramedic program and we give them half price tuition um and even with that that's it's it's tough the um and you know there's it it's really something and it seems to be somewhat cyclical with the economy also but it's it's a it's a different world now a little bit and there's just not that kind of deep pool of recruits that we used to see and it's something that we're all gonna have to work together to overcome fire police EMS everyone because we're all now confronting the same thing came we're just having a tremendous problem recruiting and everyone is doing the best to run now youth academies and connect with folks in the schools offer different programs and training it is not a pro and it's not a problem isolated to Melrose it is everywhere and it's all over the country it's not just

▶ 2:30:14 Monica C. Medeiros: here it's everywhere this is a this is a profession that's highly regarded at least among us for sure and I think throughout the community and a great

▶ 2:30:31 Monica C. Medeiros: opportunity with a relatively low economic barrier in terms of you know we see what we see in other professions for college and student loans to come in and you know have a profession that pays relatively well and yeah lifestyle and

▶ 2:30:49 Speaker 3: be our heroes so the the pay and benefits have gone up across the board for everybody but the other thing that someone said earlier in this in the session was the as it was you remember was as folks are running out these guys are running in and you know you you do have to have a certain chip in your head you do I mean it's that that is an unnatural reflex that many of us end up possessing and uh that's that's if if you have that and a willingness to learn um it's a it's a rewarding job police fire and ems thank you thank you very much alderman's work go

▶ 2:31:30 Michael P. Zwirko: thank you madam chair a few quick uh questions here and thanks for being here again uh missed you last year so appreciate you being here tonight um i just want to make one quick comment first on because it alluded to it earlier in the surveys that we get back and I think it's important for folks to remember that our ambulatory service being in-house being unified uniformed men and women of the fire department they're able to provide better care at a call for service specifically because they're familiar with the residents the clientele so to speak whereas if it's a third-party vendor that's maybe not as familiar with Melrose even the roads or the individuals I don't think the level of care is going to be as high these are our neighbors and these are our friends so I think that that's one of the reasons it's also another reason why we should continue to advocate to keeping the program in-house so I think that's that's certainly one of the reasons the the 95% approval the care that's provided at the call I did have a comment or question rather on the rates that you're that we're seeking to raise I didn't see any other market information so these rates are these generally speaking across the industry below market are they competitive with the market are they where do we feel that they're being captured yes I'm

▶ 2:32:53 Speaker 3: sorry I kind of interrupted my own train of thought which was the the rates are always a two-pronged analysis we're looking at the cost of providing the service and then we're trying to get and we're looking at the pair mix and we're plugging in a rate that will get you close to covering your cost of providing the service the second prong of that analysis is the rate reasonable and the way that we look and see if the rate is reasonable as we look at all the surrounding cities and towns that we have data on and now we actually have data on oh boy somewhere in the neighborhood of a hundred surrounding cities and towns and you guys are are pretty much just square right smack in

▶ 2:33:40 Michael P. Zwirko: the middle the increases aren't aren't exorbitant and they do seem that they're in line of just general rising costs I mean it almost just does seem like an annual increase so to speak so generally speaking I'm in favor of them thanks the questions were answered earlier on the collection rates and the various percentage of our customers I appreciate that breakdown you would think that our collection rate from insurance would be a little bit higher but apparently the government's a better payer but they're just pay at a lower rate so that's for

▶ 2:34:16 Speaker 4: sure yeah those are all the questions I had thank you alderman McMaster Thank

▶ 2:34:19 Shawn M. MacMaster: you madam chair mr. Mergen doll it's nice to see you in the chamber tonight I missed you here last evening or I should say last year and as you know we've had an opportunity to work together outside of this chamber in a professional capacity and I've had a chance to work with your team at pro EMS as well so I have no questions I just wanted to again thank you for being here and just really say that as somebody who works with police fire and EMS across the county we can't really be any more fortunate than to have pro handling our billing you guys are arguably the the best in the business you're a very data-driven organization I know you were the first to bring first watch to Massachusetts and you had an opportunity to sit here and listen a little bit to some of the questions that we asked the fire chief and you know perhaps as we move forward on trying to better support the fire department in terms of some of the technology that it needs to, you know, to do its job, we might utilize your expertise about some of

▶ 2:35:20 Speaker 3: those opportunities that exist in the future. Yeah, First Watch actually is a great opportunity for everyone to capture data. One of the questions was on overdose data, and we've got a program now where First Watch will capture overdose data and send it in real time to the people that crunched the numbers. Cambridge is very fortunate to have a very robust public health department. There's actually two or three epidemiologists on staff, and so we've got that capability. We could also work and build that up in Melrose too, where that data is sent to a central source. there's protected health information is is actually scrubbed but it allows you to collect data on the the overdose the patient's outcome age gender the location so you can actually locate hot spots where there may be more attention needed on the overdose side and so that's that's something that we can absolutely work with the chief on getting up and running and some of that

▶ 2:36:44 Shawn M. MacMaster: data might be helpful for our efforts and looking to obtain grants that exist to support some of our needs but again thank you for being here thank you for all of your work please extend my thanks and my regards to your team at a pro

▶ 2:36:58 Speaker 3: sure well thank you nice chair boys oh going back to

▶ 2:37:02 Robert A. Boisselle: recruitment you mentioned going to the schools and other places but have you done an outreach to the military the veterans that are coming out of the Iran

▶ 2:37:15 Speaker 3: Afghanistan the medics and so forth yeah it's you know that's really a heck of a study in bureaucracy when when you come out it's you're very well trained to be an EMT but you would actually have to take quite a bit and you're actually like have training that's well beyond being an EMT but that's really to handle more trauma and to be a civilian paramedic requires a lot more on the medical side so the the folks who want to go come out of the service and become a paramedic would almost have to take the entire paramedic class again even though they've come out of the military in some pretty precarious situations and I've seen a lot but they the it and there really is no good bridge program that program that bridges the military medic into the civilian role it's been tried in a few places but they haven't been able to really make it work all

▶ 2:38:23 Robert A. Boisselle: that well is there a reason why it's not working well is it more financial or just basically the individual becomes bored and he's that individual is well beyond the training that he's receiving yeah we have we we actually in our for

▶ 2:38:35 Speaker 3: our paramedic program we usually have each class oh so we have two classes and and we max out at 42 in each class there's usually a waiting list and we actually usually reject actually a fair number of people too but usually have four or five folks that are on the GI Bill in each class but it's it's hard

▶ 2:39:02 Speaker 3: when you come out of this out of the military and you've been in that role and you've been in some some pretty tough spots and had a lot of training and had a lot of expectations to go back and sit through another year of school that's a tough one so I think that's one of the barriers for sure to making the

▶ 2:39:32 Speaker 3: transition I think it would be easier if we all nationally and and the EMS is not only regulated at the local level but it's very much regular at the state level and if there's some way to somehow herd herd all the cats to get a training and regulatory framework where we could better bridge someone from military to civilian rather than an entire year I think that would help tremendously but we haven't seen the capability to be able to do that yet okay thank you thank

▶ 2:40:04 Speaker 1: you madam chair any further questions or discussion we have two orders that have

▶ 2:40:15 Michael P. Zwirko: been joined before us I don't know if it should be two separate motions or not but I'll move one to approve the bottom line of the ambulatory budget second

▶ 2:40:24 Speaker 1: okay we have a motion to move the bottom line of the ambulatory budget that is duly seconded all in favor aye opposed okay that will be recommended to the

▶ 2:40:36 Michael P. Zwirko: full board move to approve the rates as proposed in the outline outlined in the

▶ 2:40:44 Speaker 1: accompanying memo okay so that was moved by Alderman Zwirko to accept the rates proposed or the fees for fiscal 20 seconded by Alderman Tramontozzi all in favor aye thank you so much for being here tonight thank you thank you