EMS Subcommittee

Monday, January 13, 2025 - 9:00 am

Robin DeLoria - Chairman

Chairman DeLoria called this EMS Subcommittee to order at 9:00 am with the following in attendance: Clayton Barber, Chris Clark, Robin DeLoria, Derek Doty, Shaun Gillilland, Ken Hughes, Jim Monty, Favor Smith, Matt Stanley, Ike Tyler, Meg Wood, Mark Wright, Mike Mascarenas, Josh Favro, and Matt Watts.

ALSO PRESENT: Dina Garvey

DELORIA: Okay, we will get this meeting start. So, Shaun, did you want to go first?

GILLILLAND: No, go ahead.

DELORIA: Matt, go ahead with your meeting here.

WATTS: We do have one resolution that we will be bringing to the Public Safety Committee for adopting our new billing rates. EMR, went through and gave us some recommendations based on what everybody else is the industry is doing, so that’s attached on the last page of the packet. Were our old rate versus where the new rate is going to be and Michael, actually broke down what it costs us to do an intercept. Basically, it costs us, $242.00 for the time and the supplies that we use and stuff to do the intercept.

DELORIA: And the bill goes to whom? Who are we billing?

WATTS: The agency.

DELORIA: Okay, any agency?

WATTS: Yup and they get reimbursed from the insurance company. So, even if they have a BLS provider on, they’re still billing it at the ALS level, because we’re onboard and then we just bill the agency and recover the difference that they would get.

A couple of new ones where if we do an assessment and deeming that the patient doesn’t need ALS services, we can bill that for $75.00 and then for like a cardiac arrest where we do a lot of procedures and use a lot equipment and stuff, as an ALS contractor, we can bill it at a higher rate, also.

DELORIA: Is that a flat rate or hourly?

WATTS: It’s a flat rate.

DELORIA: All these flat?

WATTS: Yes, yup

DELORIA: Okay

WATTS: Yup, any questions on that?

STANLEY: Now, these billing rates are just directly to the agency, not to insurance?

WATTS: Correct, except for Medicaid, where Medicaid gets billed, because that’s a separate thing.

GILLILLAND: Who bills Medicaid, then? The County?

WATTS: The County would, yup, EMR would and we can bill them from the $200.00 or $300.00 and we would not get that much, but.

GILLILLAND: So, it just kinda of seems to me, from the philosophical point of view, here, that we’re billing agencies, some who bill insurance and some who don’t.

WATTS: I believe everybody is billing now.

GILLILLAND: Schroon, are you billing insurance?

WOOD: I’m not billing.

GILLILLAND: No, the agency.

WOOD: Yeah

MASCARENAS: They are now, they got on board.

GILLILLAND: So, we’re going to Medicaid here, and then we’re going to agencies and each agency is going out and paying 5%, I think 5%-10% to their billing agency.

So, basically, the County is billing an agency.

WATTS: Yes

GILLILLAND: And then that agency is billing, so we’re paying to bill the agency, basically in opportunity cost and the agency is going out and losing 10% of the revenue on that and it’s just, I’ve had this vision for a long, long time, of central billing. If we bring them all in and the County bills on behalf of, under contract with each of the agencies, when we’re in a better negotiating position with each of those billing agencies, because there’s a heck of a lot more bills going out.

STANLEY: So, we’re trying to do that in, with the AuSable Forks Ambulance Squad and I tell you, it’s been a cluster, to say the least. Because the billing starts from the paramedic doing the PCR. So, nothing happens, it doesn’t matter, like we’re taking it over as a town, but it’s going to be tough, because if a PCR doesn’t get filled out, that call doesn’t get billed.

GILLILLAND: Right

STANLEY: Like, it’s tough enough for us to chase across the road, having them to chase, what 20 agencies? To try to figure out, okay, so who was on this date, that this PCR didn’t get filled out, on this call? Who do we need to go back through to find out? I mean, it’s and a lot of that, I think, we fall, we’re just starting with EMR, as of January 1^st.

GILLILLAND: What’s going to happen in 10 years, when the majority of the EMTs out there are County employees?

STANLEY: I think when it’s a countywide system…

GILLILLAND: Well, that’s what we’re building for.

STANLEY: Right, but we’re not there, yet and the thing that we’ve got, is we’ve got these agencies, we have these agencies that don’t even want to deal with the County. So, if you can try, if we at least slowly assist these agencies to get there, I think there’s, I mean slowly turn the ship and take it over, is what I think we need to do, because that’s where it’s going to end up being.

GILLILLAND: Well, then you and I are in agreement on that.

STANLEY: Right

GILLILLAND: I’m not saying, you know, by Tuesday, start billing everybody. I am saying, let’s build a detailed plan and in that plan, let’s try and find, okay, where are the landmines and where are the successes on that. Including, maybe calling EMR and whoever the billing agencies is and so, if I have 20 agencies and so many thousands of bills going out, you know, I am going to be in a better negotiating position than if I only have 20 bills going out.

STANLEY: Well, I will say, for us moving to EMR, I think it’s going to better for us. We had Medex in the past and it was a, we pay you one fee whether you recover money or not. EMR, we’re going this year to, you get a percentage of what we recover. Which I think will be a huge thing, because I feel like we lost a lot of revenue, because the bill was sent out and it was just never followed up on.

WATTS: But, you were still paying?

STANLEY: We were still paying, we were paying $600,000.00, between us and Black Brook, for an agency to run. So, I think we’re thinking about exactly the same thing, it’s just coming at it in different ways, so, I agree.

GILLILLAND: That’s my paid advertising.

WATTS: I think it’s a great idea. I know Mike and Michael and Josh and I are going to get together.

MASCARENAS: Yeah, I’ll talk about that in a little bit.

FAVRO: And trying to get these agencies to understand, if you don’t have to deal with as much with the billing and do what you do good, which is taking care of patients and understanding, we don’t want to take over, we just want to help create more revenue for you. Is what we’ve been trying to do.

DOTY: How much more clerical would be need to pull something like this off?

MASCARENAS: It’s a great question.

GILLILLAND: If we’re running our own ambulance, if you’re running our own ambulance, we’re going it anyway. So, we just have to expand that capability. I am just working with the point of view of saying, every agency that is contracted with the County, gets a check from the County for their services. That begins the whole tied together of all the agencies under the County. So, that when, I think everybody in this room agrees, eventually, we’re going to be at a County system, every County in the State is going to be there. It’s just trying to build the infrastructure there, so when it does, it doesn’t get shoved down our throat on a Tuesday.

MASCARENAS: EMR, are they now, is there any other medical billing agencies working in Essex County for EMS?

WATTS: I don’t think so.

MASCARENAS: So, Jay was the last. I know that there were only a couple.

WATTS: I’m sure that Lake Placid. I’m not sure who they use, do you?

DOTY: For EMR?

WATTS: For billing?

DOTY: I don’t.

WATTS: I don’t, I think they are different.

DOTY: As far as employees, who they use?

WATTS: No

MASCARENAS: No

WATTS: Medical billing.

REUSSER: There’s private people that do it.

DOTY: I don’t think they contract with anyone.

MASCARENAS: Most people are under contract with EMR.

DOTY: I think they do everything in-house.

FAVRO: Hannah Marshall, used to do it in-house.

DOTY: Doesn’t Hannah, do it?

FAVRO: She used to, I don’t know. That was a long time ago.

MASCARENAS: EMR, equips you with the IPads, they equip you with everything you need to do that billing and that administrative burden is passed to them, which is kind of nice.

WATTS: Westport, just started billing, not too long ago, within the last few months. I think they were the last ones.

DELORIA: They use the IPad to generate the PCR reports, correct?

MASCARENAS: Correct

DELORIA: We have PCR reports that aren’t getting done and turned in?

MASCARENAS: I don’t know that. So, I think, what I will tell you is, yes, because if you look at the revenue sources in each squad, they vary within a similar call volume.

WATTS: Right

MASCARENAS: So, if you looked at call volumes and you looked at revenues and how that works, you can tell some agencies are very good at it and some agencies are not very good at it and you can just by knowing those numbers.

WATTS: Some of it has to do with the documentation that they’re doing, you know, if they’re doing poor documentation they’re going to not get as much reimbursed, either. They’re going to get claims denied.

GILLILLAND: If EMR has got the majority, it’s kind of like you borrow $100,000.00 from the bank, the bank owns you, if you borrow $5 million from the bank, you own the bank. I mean, you know, we tell EMR, you want our contract or you’re out of business in Essex County?

MASCARENAS: I feel like Lake Placid had EMR, because they’re percentage was different.

WATTS: They might, they’re the only ones I can’t remember.

FAVRO: And I am going back, like 10 years, at least, from my knowledge.

MASCARENAS: Yeah, I felt like their percentage was lower, because they had higher call volumes.

DOTY: Their call volume is a 100 a month, 1,200 a year.

MASCARENAS: Yeah, so EMR is going to base their rate on return, based on some call volumes and those types of things and I felt like when we initially looked at that, but I could be wrong.

WATTS: Yeah, I don’t remember.

DOTY: Are active transports a line of revenue for our county system? Like you run ambulances, different towns run their ambulances to Albany Med, UVM or do you contract them out?

MASCARENAS: I think it’s hodgepodge, pretty much, right?

WATTS: The transports are done by HealthNet and Lamoille.

DOTY: Okay

GILLILLAND: Sorry to hijack this.

MASCARENAS: Lewis does some of those, too, right, Elizabethtown?

WATTS: Rare

MASCARENAS: Yeah

WATTS: Like if it’s a critical patient and HealthNet’s not available or whatever.

FAVRO: I believe Lake Placid will to, right? They help Saranac Lake, vice versa?

DOTY: They’ve been offered to help Saranac Lake, but have originally not responded. I am embarrassed to say that, very poor.

MASCARENAS: Sorry, Robin, we kind of hijacked your meeting.

DELORIA: No, it’s all a good conversation.

BARBER: All of Chesterfield’s billing is done through CVPH.

MASCARENAS: Right, you contract with CVPH.

BARBER: Correct.

REUSSER: What’s their take? Are they 10%, as well?

BARBER: I don’t know.

STANLEY: They just, from my understanding, you guys just contract with CVPH through the Keeseville Fire Department and don’t even worry about it, any of it.

BARBER: Right

MASCARENAS: So, there probably is no percentage. They’re actually the people performing the, they get it all. The Town of Chesterfield, isn’t getting any revenue of this, just cost.

DELORIA: Can you send us a list of the agencies that are currently using EMR?

WATTS: Yup

DELORIA: That would be a good start and the call volume of those agencies.

REUSSER: Will that go out to everybody, Matt, because I am not on this committee, but I’m really interested.

WATTS: We can do that.

DELORIA: Okay, staffing updates?

WATTS: I don’t have anything for that. Contracts; we just got them back the other day, so we’ll start sending those out. We got a draft and then we sent it back with a couple changes and so, we just got them back.

Keene/Keene Valley, did contact us, that they’re possibly looking at getting some services. So, we’ll stay tuned for that.

DELORIA: What are they up to?

WATTS: What’s that?

DELORIA: What is it with Keene and Keene Valley?

WATTS: They’re looking for possible staffing.

DELORIA: Do we have any of them on our EMS side, right now?

WATTS: No, not currently.

The AEMT Course is still ongoing. I believe it ends, maybe the end of this month or sometime in February and then there’s an EMT course in Ti, scheduled for March.

MASCARENAS: How many, Matt?

WATTS: How many?

MASCARENAS: Registered.

WATTS: I don’t know how many are registered for the one in Ti, for the EMT. There’s still about a dozen in the A Class, that are still participating.

MASCARENAS: Good

WATTS: And most of them are doing well, from what I understand.

MASCARENAS: That’s good.

WATTS: The paid per diem thing, there’s no change from last month, either on that.

WOOD: So, Matt, I have a question, how many people have answered you, like Schroon Lake, has and said they’re not interested? Because that’s not in here.

WATTS: Interested in?

WOOD: The paid per diem.

WATTS: Only, the only response we got is Keene, so far.

WOOD: You got one from Schroon Lake, because I have a copy of it.

GILLILLAND: And I have here from Willsboro, many weeks ago.

WATTS: Okay

WOOD: This went out…

WATTS: So, we did hear from Willsboro, but we didn’t get an actual formal request. This is the first time we’ve seen this.

WOOD: It was mostly just telling you, thank you, no thank you.

WATTS: Okay

WOOD: But, at least you can strike that off the list.

GILLILLAND: The thing about Willsboro, Willsboro/Essex, is it has the possibility of, because I was at the meeting the other night with them and of course he went through the whole philosophical thing. You know, and I tried to explain to them that those is not a recruiting incentive, this is an incentive to reduce attrition.

WATTS: Yup

GILLILLAND: And the thing is, Willsboro/Essex, I mean in the 4^th quarter, we dropped 20 calls. Now, that’s bad and all the calls they dropped we’re between 9:00 PM and 6:00 AM.

WATTS: Yup

GILLILLAND: So, you know what’s happening.

WATTS: That’s when we don’t staff it.

GILLILLAND: So, you know, I think we really need to move forward on this and I noticed that you said that you gave letters to all the agencies. Did you send one out?

WATTS: Yes

GILLILLAND: Can you share that with the Supervisors?

WATTS: It was quite a while ago, but yeah. I can send you the copy that we have.

WOOD: It was a long time ago.

WATTS: Yeah

WOOD: Because our ambulance squad head is on our Town Board, so I am always ragging him on it and he finally emailed me a copy of what had been sent.

GILLILLAND: Because, I mean, this needs to be pushed. Of course, they invited me and they invited Ken, to this thing. Ken, had a Town Board meeting and couldn’t go, but you know, as far as our squad goes, they’re confused and I don’t know, if that’s an issue of they don’t know the process, but we need to get the process out there to, so it makes it easy for all these agencies to go forward with this. For me, it’s not from a lack of desire, it’s they don’t know how to do it.

STANLEY: So, maybe it’s a lack of education and maybe if you can send something to all the Supervisors and we can go to our individual agencies to explain what it is, instead of just a letter. Because, obviously the more that we can get volunteers involved, the cheaper it’s going to make the service of the entire County.

GILLILLAND: That’s correct and a longer period of time.

STANLEY: As long as we can.

MONTY: Question; have we considered, you know, like Shaun, said, 20 of them we’re between 9:00 at night and 6:00 in the morning, have we considered staffing at that time? I mean that’s what our goal is, is to provide these services. If we’re seeing something historically, in this timeframe, should we be trying to staff for that?

MASCARENAS: Jim, I think the issue we’re running into and I had a talk with these gentlemen the other day and my goal for 2025, is to ramp up with a real action plan. I didn’t’ want to bog down Robin’s meeting.

DELORIA: No, go for it. We need to get it done here.

MASCARENAS: But, you’re absolutely right. What’s really happening in here, we’re a temp agency.

MONTY: Yeah, no doubt.

MASCARENAS: But, the employees that we even have still feel like they work for the agency that we put them and that’s where we haven’t done a great job of kind of utilizing our resources to the fullest extent. So, we’re not driving the agencies when they have these dropped calls from 9:00 PM to 6:00 AM. If they came to us and said, hey, we’re dropping all these calls, we’d like to hire more staff, we would do everything we could to hire them and give them the staff they need, but the answer is no. We’re not, we are not dictating how an agency currently runs and operates.

DELORIA: Right

MONTY: I think that’s the point I’m trying to make. We need to start dictating that, if we’re footing the bills for it.

WATTS: I think we need to have more administrative authority within the agencies.

MASCARENAS: Yeah

STANLEY: The only problem that you are going to run into with that, though, is you’re going to get pushback from the agencies.

MASCARENAS: Yes, we are.

STANLEY: And then we’re going to take it all over.

HUGHES: Well, then there needs to be some kind of incentive. If we’re going to get in there, then there should be an incentive to them, somehow to make it work.

GILLILLAND: But, I think step one should be those temps, I mean per diem employees.

DELORIA: Yes

GILLILLAND: They’ve got to try and make that work, before, I mean, if they can’t roll in a certain amount of time and they drop so many calls, then their authority is gone.

HUGHES: That’s the landmine they go into.

GILLILLAND: The philosophy is, we’ll take over, if you can roll, right?

MASCARENAS: Yes, absolutely. In communities where we already have County employees, there’s contractual and policy directives that are already in place.

HUGHES: Yes

MASCASRENAS: But, I don’t know that we’re doing a good job onboarding these people through the door and letting them know that you’re a County employee; right? So, DSS is a 24/7 operation. You can replicate a lot that goes on there and how we man that and staff it and we have these things in place. So, if you have a County employee in Willsboro, there’s nothing prohibiting us from saying, we’re going to pay that employee $3.00 an hour to be on call and we’re going activate their normal rate of pay, it’s contractual. We can do it with any employee that we have, not just DSS. So, at any given time, now do we have to look at drivers and maybe including some of them, absolutely, because a paramedic is no good without a driver, right? We need somebody that can get them there. But, where we have fallen in the last year or so is pushing this is the next level. Where we’re not going great on the planning side. So, what I have asked these gentlemen to do, following the CGR Report, let’s look at some of those suggestions by CGR, but let’s really look at a 3-5 year plan. What’s our demographics look like of our workforce that we have there? How many of them are going to retiring in the next few years? Where can we anticipate we’re going to have more problem areas and how do we ramp up to be able to meet that need in a worse-case scenario? Because, right now, the answer is, we don’t know. What I can tell you is it’s going to happen and the whole thing will implode if we’re not prepared to do that. So, is billing part of it? The answer is yes, but we need to be at these agencies. We need to have our administrative staff going in there regularly and meeting with them and working with them on some of these transitions. Do we want to take over? Absolutely, not. Is it inevitable? It likely is. Bryce, was on the right track. He was just jumping in terms of regionalizing some of this type of service, so that we can make that call between 9:00 PM and 6:00 AM. But, what is that going to take? That’s going to take looking at a map, looking at the numbers; right? How do we intersect these two different areas so that we have multiple coverage in these areas when time is needed. Do we need more ambulances to be able to do this? Do we need more fly cars? Personnel that are working those hours, you know, while we await an ambulance? Those are the unknowns. We know we do, but can I give you the specifics? No. So, we’re going to sit down, real soon and any of you are welcome to attend and the Chairman is welcome, Robin, certainly and work on template of what I’m looking for these gentlemen, over the next few months So, we have a 3-5 year plan of action and how we get to, not only something that’s efficient, but effective. People in the service industry have all the best intentions, but when you leave the planning to them, it’s all about the service, the cost is never considered. You start taking that siloed approach to, there’s no big picture here and we just say, yes. That’s what we’ve done lately, right? so, Ticonderoga, says, I need a new person, we say, yes and it’s over. Well, what? We don’t that with every other thing we do; right? We need to provide an analysis, we need to be able and then utilize that staff if we have holes in other areas, it’s not just a Ticonderoga person, you’re a county worker.

TYLER: You know what I think would help, Michael? Listening to this conversation, is not have just the Supervisors go to the EMS, but have a County person with them, introduce them, if they don’t know, if they do know them, fine and make sure that they’re all a team, because in some cases, EMS had personal problems against the Supervisor or vice versa. But, I’m just thinking it would be good educational for the County person to be there to help educate what’s going on.

MASCARENAS: Yeah, we’re recognizing that and we cut that full-time job. We may have to look at it, it’s a recommendation in the CGR report. Right now our person is pulling dual duty. They’re acting as a paramedic and as the administrator and I’m thinking that’s where we went astray in terms of that and we’ve lost momentum.

DELORIA: And you know the agencies don’t have the ability, essentially, to administer this type of program.

WATTS: They think they do.

STANLEY: But, I think we also need to be ready for the worse-case. If we end up having to take over, how quickly can we get staffing? How quickly can we get ambulances? How can quickly get coverage and locations to house and operate from? I mean, I think there’s a lot of stuff that needs to go into this so that we don’t have, get back to where we start dropping calls, because an agency just says, fine, you do it then.

MASCARENAS: You’re right, right now our biggest area of need, from my standpoint, where I see is Willsboro/Essex, they’re struggling.

WATTS: Yes

MASCARENAS: Ticonderoga, Moriah. Ticonderoga, Moriah’s not struggling with missed calls.

WATTS: Not in Ti we haven’t.

MASCARENAS: But, why; right? And the reason is because, we’re providing an awful lot of resources to those communities, right now and the more resources we provide, we need to have a say.

WATTS: Absolutely.

MASCARENAS: Because, now you’re spending our dollars, in terms of those efficiencies and what that’s looking like. So, to me, those, his community is a really good pilot, where we can draw up a blueprint that’s going to work when others fall off and come off line, but knowing when that’s going to happen, is not a perfect science, but we can have a pretty good idea, if we do our homework.

STANLEY: Well and understanding and knowing the outlining areas. Like Chesterfield, uses CVPH. We actually use a lot of per diems that come from Morrisonville, CVPH. We only have two full-time employees, there’s like 15 per diems.

MASCARENAS: Robin’s story was the same as yours this morning.

HUGHES: It would be good to take a look at those dropped calls between 9:00 - 6:00, how many of them are for 10 Gillilland Lane.

GILLILLAND: That question came up.

HUGHES: Yeah, because they were always, not always, but most of time they’re just…

GILLILLAND: It was basically that the percentage was the normal percentage of what it is in a 24 hour run.

HUGHES: Really?

GILLILLAND: Yeah

HUGHES: Okay

GILLILLAND: In fact…

REUSSER: There are obligations for services such as that to have a mechanism in addition to EMS to access those situations.

GILLILLAND: The problem is, they do go to the first thing, what drives that is the on-duty nurse makes the determination as to whether it’s a non-medical transport or medical transport. Those people, it’s a medical decision that they’re saying, that this person has to go. They are a lot less than they used to be before, as far as those transports go.

REUSSER: Well, hopefully that’s a registered nurse.

GILLILLAND: Yes, it is a registered nurse, but the, I mean that’s almost a microcosmic of what’s going to happen to our communities. I mean Office for the Aging does a tremendous job trying to keep people in their homes for as long as possible. A lot of people are sitting in homes, in my community, that probably shouldn’t be at home. So, more and more of these are going to be those kinds of calls, because the first medical person that shows up is going to be the ambulance after a fall.

MASCARENAS: Those are demographics, the fastest growing population is our aging population.

Well, that got out of hand (laughter).

DELORIA: We know there’s problems there and again, I don’t think we’re consciously ignoring them, but I honestly think we’re consciously addressing these problems before we get this domino effect and then it’s going to be a Countywide program, it’s going to cost a hell of a lot more than it costs now. So, these per diems, I’ve been hounding per diems, since day one, when I took this chair and where are we on it. That’s where this 3-5 year plan is and hopefully 1-3 was can build it. We got to, it’s the only way it’s going to work, I can tell you that right now.

GILLILLAND: It’s the only way we can afford to make it work.

DELORIA: Yup, affordability.

MONTY: Quick question, the 38% drop in Medicare money, is that because the 4^th quarter isn’t in or is it an actual 38% drop?

WATTS: I will have to get that to you. I can let you know. I will send that out to everybody.

DELORIA: We will adjourn this and we will be back here, again.

MASCARENAS: We’ll l have a template for you next month.

DELORIA: That’s fine, send it to me and I can add to it.

We stand adjourned.

AS THERE WAS NO FURTHER BUSINESS TO COME BEFORE THIS SUBCOMMITTEE, IT WAS ADJOURNED AT 9:30 AM.

Respectively Submitted,

Dina Garvey, Deputy Clerk

Board of Supervisors