The Warren City Council on Monday agreed to hire legal counsel to address all of the issues related to ambulance responses outside city limits.

That may have been the only issue where action was taken on Monday, but proposals and ideas outlined during a work session would drastically impact how the city provides EMS services.

City Manager Nancy Freenock said the city is “increasingly concerned” about the increasing number of ambulance calls outside the city.

“Every time we try to do something about it, we’re met with a lack of a response,” she said. “The volunteers do a great job,” she added, but claimed some are aging out of service while others have full time jobs.

“City taxpayers,” she said, “have been subsidizing” responses into the townships.

Freenock said the purpose of Monday’s work session was to ask the council for advice and also discuss potential fee changes, whether the city should leave the county’s EMS response plan and how to enhance the existing ambulance membership program.

Fire Chief Dave Krogler said he’d like to see cooperative management agreements with municipalities to ensure that the city is compensated for the services it provides. The current EMS response plan was designed for agencies to cover each other when one goes out of service. But the plan has been largely unutilized while the city’s calls for service outside the limits increase.

Operations and Training Officer Steve Hoffman said the EMS response plan was a state mandate.

“If we withdraw from the plan,” Councilman John Wortman said, “(there is) nothing saying we can’t enter into separate agreements” with municipalities.

“It creates a political firestorm” and an “antagonistic mindframe” if the city withdraws then attempts to negotiate, Councilman Gregory Fraser said.

Hoffman proposed diplomacy before withdrawing out of a need to work together to solve the problem.

“If you get out of the agreement you start fresh,” Mayor Maurice Cashman said.

Fire Chief Dave Krogler said the plan “provides a framework” for when a department knows it can’t provide coverage. He said Clarendon has requested coverage a couple times. “Outside of that I have not gotten any requests.”

Cashman suggested the city could provide a 90-day notice to withdraw and say coverage agreements would be needed in turn.

There are structural problems to how the city is paid for the EMS services it provides.

“We are not permitted to balance bill Medicare or Medicaid,” Freenock said. Balance billing is issuing a bill to the patient or supplemental insurance above what the government pays in reimbursement.

She added that there are calls for which the city can’t bill at all such as situations where a patient is treated at their home and not transported or when the department is called out for a lift assist.

Hoffman said the department has been working to calculate the annual cost of providing EMS but also a per-call cost.

Data through the end of August shows an average revenue per call of $332. Self-pay and commercial insurance are around $430 per call but the average is drug down by the Medicare rate — $356 — and, to a greater degree, Medicaid’s reimbursement rate — $186 per call.

The challenge is that in excess of 80 percent of the city’s response calls fall into those lower reimbursement categories — 63.9 percent are Medicare calls and 19.6 are Medicaid. Those percentages, Krogler said, are nation-wide and not unique to this region.

The end result is that the city receives far less in payment than what it issues bills for.

“We receive about 65.9 percent of everything we bill out,” Hoffman said. “If we’re billing out $100,000, we would see about $65,900. That’s where we see that disparity… those low volume calls with the high yields. The disparity is so wide it hurts us.”

The city is a basic life support agency and currently charges $400 per BLS call. Hoffmain told the council that the state average is $903 and that Bradford, a city of comparable size, charges $850.

Hoffman said the city structured the rate that way because city residents were already contributing to the cost of providing the service via their taxes. “City finances are being lost outside the city lines,” he said.

He then proposed a series of changes to the city’s fee schedule — raising the BLS rate to $800, increasing the advanced life support fees from $700 to $1,200 and increasing the mileage rate from $10 per mile to $15 per mile. The proposal would also implement a $100 fee for a “treat, no transport call” as well as a fee for lift assists. Some of the fees are structured to be different for city residents and non-city residents.

Hoffman explained that volunteer agencies in the county charge $800 per call but don’t have the labor cost that the city does.

Krogler added that part of what someone is paying for with city EMS service is the knowledge that a response is coming. The city operated a 24/7 service. He equated it to purchasing car insurance where that guaranteed response is part of the package.

These changes, though, would not impact the overwhelming share of Medicare and Medicaid calls for which the city responds.

The 2021 city budget allocates nearly $3.2 million to the Fire Department, which manages EMS response. Data from Monday’s meeting indicates that $1.068 million of that total can be attributed to EMS directly.

For 2021, Hoffman said the average cost of a call is $828.72.

While it’s possible to nit-pick that number in a myriad of ways — many of the city’s structural costs, especially personnel — will remain regardless of whether the city responds outside the limits or not — Hoffman told the Times Observer that there has never been a plan on how to develop a cost structure in the past. And detailing those costs is the first step in any negotiation.

He also noted, though, that even though the city will have the personnel cost anyway, the city’s “response potential” for EMS and fire in the city will be decreased if staff are out in the townships. That increases vulnerability, per Hoffman, and Krogler said that is a “cost to the taxpayers.”

Krogler said these numbers represent a “general idea of the cost to run an ambulance call.”

Using that number to then extrapolate the total cost of EMS services to calls outside the city, data from the city estimates that total at nearly $110,000.

The numbers are broken down by department coverage area rather than municipality at point. Over half of that $110,000 total is allocated to Pleasant Township with about $20,000 combined for North Warren and Starbrick, the two departments that cover Conewango Township.

Hoffman said the city responded outside the city 300 times last year. “The City of Warren tax base can’t continue to flit this bill…. It’s going to come down to establishing that rate fee.”

For 2020, the city responded to 1,794 calls in total.

Council recognized it needs legal counsel on these issues and approved a contract with a firm during the regular meeting held after the work session.

Wortman said it’s his belief that the best course of action is to “withdraw” from the response plan “and negotiate with whomever is interested.”

“I don’t think we (should) go out and start negotiating coverage agreements” on our own, Cashman said, recommending the firm be hired to handle all aspects of the EMS situation.

“If we don’t act in some fashion, the problem is only going to get worse,” Wortman said.

The city acknowledges that it would take a year for townships willing to negotiate to adjust their budgets.

But a delay is “putting the taxpayers in a bit of a compromised position,” Fraser said.

“I don’t believe you have time,” Hoffman said. “The way it’s precipitated and growing and just compounding on itself, as it continues (the EMS system) will become unsustainable and will fail.”

Fraser said the current situation paints a “pretty grim picture for a lot of these townships. At least half of them are going to say no.”

He said he hopes council realizes the “political firestorm (this is) going to create. It will bleed all over the county. Someone’s got to make a decision. That’s us.”