Public Health

With EMS Changes Shot Down, Some Are Asking 'Now What?'

A study concluded the Washington state county’s EMS system was too fragmented.

by Brandon Stone, Skagit Valley Herald, Mount Vernon, Wash. / January 9, 2017

(TNS) - When the Skagit County, Wa., commissioners organized a group of 24 to look at the future of emergency medical services, many thought it was an opportunity for candid talk about the county’s ambulance systems.

Now, after a meeting in late December where the commissioners went against a recommendation to continue looking at how emergency medical services should be governed, some members of that group are feeling their eight months of work was all for nothing.

“They weren’t looking for the answer we gave them,” said Mike Noyes, chief of Skagit County Fire District 11 and president of the Skagit County Fire Chiefs Association.

The Delivery Model Advisory Group’s recommendation — by a 15-3 vote — was for the commissioners to consider further research on an EMS district, which would have created a government entity separate from the commissioners to manage emergency medicine in central Skagit County, replacing the Central Valley Ambulance Authority (CVAA).

By sticking with the existing system, the commissioners “made a decision to be indecisive,” Burlington Mayor Steve Sexton said.

When the group first met in April, it was the first opportunity in years for so many stakeholders from across the county’s EMS system to be in the room at the same time.

They quickly agreed the patient care aspect of EMS was excellent, with Commissioner Ken Dahlstedt and others often saying “we haven’t heard any complaints.”

The focus then shifted to what many felt was a shortcoming of the system — its governance — and away from the specifics of staffing and distribution of ambulances in the county.

In order to address larger issues, getting a new governing board was essential, Mount Vernon Mayor Jill Boudreau said.

“In our city, we don’t wait to see if we get complaints before trying to make something better,” she said.

Advocates of an EMS district say it would create an organization where the focus is solely on EMS. Board members could devote all their attention to EMS, and react more quickly than the commissioners.

Boudreau and others see the commissioners’ decision as another in a string of poor choices about emergency medicine.

“(The county spent) thousands of taxpayer dollars funding studies all coming to the same conclusion,” Sexton said. “Unless it tells them what they want, they kick it to the curb.”

In 2013, the county spent about $88,000 on a study from Emergency Services Consulting International. The study concluded the county’s EMS system was too fragmented, and recommended the county make the CVAA a government department.

Kirk Hale, the outgoing director of the CVAA, said he is disappointed with the response from the commissioners. He said he feels his time and the time of others in the group was squandered.

“Everyone is asking, ‘now what?’” he said. “I guess we keep doing what we’ve always done.”

Many in the group, including Boudreau and Sexton, have long felt the county needs to take more responsibility in EMS and to bring the CVAA in as a county department, thereby eliminating the CVAA board and giving paramedics job security and government pensions.

“The system is set up to be completely dysfunctional when it comes to CVAA,” Boudreau, a member of the CVAA board, said.

The county contracts with the CVAA to provide ambulance services, but appoints members to its board and approves its budget. Either treat it strictly like a contractor, Boudreau said, or incorporate it into the county.

Having decision-making power split between the board and the commissioners, she added, is the “crux of an inefficient government system.”

The advisory group chose not to pursue bringing ambulance services in as a county department when Dahlstedt and Commissioner Ron Wesen said they were not interested in the additional liability.

After that, the group moved on to the idea of an EMS district.

Commissioner Lisa Janicki liked the idea of a county department for ambulance services, but saw it was a non-starter among her colleagues.

“It doesn’t matter what one commissioner thinks,” she said.

The advisory group’s shift in focus from patient care to governance was seen by some — including the commissioners — as a betrayal of the group’s original mandate. This was clear from the 17-page dissenting opinion submitted by the three who voted against the recommendation to study an EMS district.

The dissenters say the advisory group was formed to discuss ambulance policy, such as whether ambulance providers should maintain the policy of having two paramedics per ambulance or whether to consider if EMTs should be permitted to transport patients to hospitals instead of only the more highly-trained paramedics.

These standards, which are high compared to neighboring counties, are a point of pride for county policymakers and stakeholders, including Dahlstedt.

Roger Mitchell, a volunteer EMT/firefighter with Skagit County Fire District 5 who worked in medical technology for several international corporations, voiced frustration with the group’s change in focus from ambulance delivery to governance.

The group’s change in focus kept it from analyzing data on levels of care, such as which areas and times of day ambulances are most needed, he said.

“The (ambulance delivery) data is all there (and) we could have analyzed it last June,” Mitchell said. “That all got tossed.”

Sexton and Boudreau disagreed when this point was raised at earlier meetings, saying the consultant report from 2013 was based on data and analytics, and the county declined to implement the consultant’s recommendations in any significant way.

Mitchell also took issue with the makeup of the proposed EMS district’s nine-person board. The proposal was for the board to be entirely appointed instead of elected.

“(An appointed board) is not accountable to the citizens in any way,” he said.

The current CVAA board is made up of those appointed by the county commissioners, though a few members are elected city officials.

The specifics of an EMS district would have been up for negotiation, and consent from all the county’s cities and towns would have been required before a district was formed. Members of the board could have been required to be elected if that was agreed upon.

Regardless, Mitchell said the discussion about a district violated the mandate the advisory group.

When asked why they didn’t move the discussion back toward issues such as staffing and distribution of ambulances, Wesen and Dahlstedt said their place was to observe the meetings, not to intervene or direct them.

One of the benefits of an EMS district could have come from new state legislation dubbed Ground Emergency Medical Transport, which will reimburse government ambulance agencies for transporting Medicaid patients.

According to consultants, the bill could provide several million dollars to the county, but would likely require the entity transporting patients to be a government agency with taxing authority.

If true, the CVAA would not qualify, but a standalone EMS district or a county department would.

However, the final shape of the legislation is undetermined, and Dahlstedt, Mitchell and others cautioned against building a system just to take advantage of a speculative source of money.

“Federal money always comes with strings attached,” Dahlstedt said.

Proponents of an EMS district, however, downplayed their interest in the legislation, saying it would be a nice bonus if it happens but that a shift in governance is beneficial on its own.

When the commissioners declined to follow up on the advisory group’s proposal, they said hiring a permanent EMS director needs to happen before any major changes in the system are made. Janicki said the county hopes to advertise the position soon.

When a new director is in place, Wesen said he would be receptive to a more detailed proposal on a change in EMS governance. He said the idea of an EMS district was concerning only because he feels the appointed board would lack accountability.

Dahlstedt, however, disagrees, saying a district wouldn’t help patient care or efficiency without a buy-in from Aero Skagit and the city of Anacortes — the county’s smaller ambulance providers — and neither has shown interest in being brought into a countywide system.

— Reporter Brandon Stone:, 360-416-2112, Twitter: @Brandon_SVH{p style=”margin-bottom: 0in;”}


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