By By JOHN EBY / Dowagiac Daily News
"We're going to have uninterrupted ambulance here," vows Jackie Evans, who directs the Dowagiac Volunteer Fire Department service. "I've assured township officials that's our priority – continuing this ALS (advanced life support) level and the responsiveness that we have."
The ambulance service, a private, non-profit entity independent of city operations, got a boost Monday night from Dowagiac City Council, which approved a $15,000 short-term "bridge loan."
All draws from the 30-day line of credit shall be utilized solely for payment of payroll, payroll taxes and fringe benefits. The line of credit shall be without interest unless there is a default, then it would be 6 percent. The loan is to be repaid in full within 120 days.
"Every time we get a scheduled Medicaid payment, the city gets a percentage of that paid back immediately. Hopefully, it will stay open, but not be needed," Evans said in an interview Monday afternoon in her office at the fire station.
City Council "is helping us out because we ran into a situation a couple of weeks ago where there wasn't enough money to cover payroll," Evans said. "We needed some immediate help, so they stepped up to the plate and helped us out."
"We run into this the first of every year," she continued, "it's just never been as bad as it has been this year. Every January, Medicare patients and insurance patients have to start meeting their deductibles again. Seventy-seven percent of our income is at a locked-in rate, so that 77 percent has to meet their deductible the first part of the year. Until their deductibles are met, our insurance payments drop off, but this was the first zero payment. We've been running tight for some time."
Going forward, Evans said the ambulance service entertained a request for proposals and will be interviewing managers – even though that could put her out of her job.
"I have a basic EMT (emergency medical technician) license, so I'll still be able to work on the truck, like I do now. I just may not be the boss. My position as director will be in limbo," said Evans, whose husband, Guy, is a lieutenant with the Fire Department.
"I signed on to make this service succeed," she said. "At the end of the day, 'succeeding' means the ambulance service still exists, it continues to exist in the future and the employees continue to have a good place to work – maybe even a better place. That will be what I call a success – securing a solid future for my excellent staff and for this community. Thursday, in the middle of all of this, my partner and I responded to my father-in-law's house and took him to the hospital. That solidifies for me the importance of this service. It's not a matter of can we have it? We have to have it. I see this as a restructuring opportunity. Forty years ago when they started this service, it wasn't so I'd have something to do. They started it because the service was needed. We're not letting go of a proud tradition, but securing it for the future."
It's tentatively set for next Tuesday, March 6, to review proposals.
The service asked for short-term proposals of a couple of years to restructure the service and return it to firmer financial footing and an option for longer term.
"We know the need is here to have at least an emergency ambulance 24/7," she said. "Proposals are going to basically state that anybody who wants to come in and manage us has to commit to maintaining an ambulance in Dowagiac, 24/7, 365 days a year – just like we have right now. We have to maintain at least our emergency ambulance. We are under contractual commitment and just personal commitment to the community to make sure that every time 911 gets dialed, there's an ambulance rolling out the door that's based here locally so response times are kept at a minimum."
Evans believes the very structure of emergency medical services needs to change if small services such as Dowagiac's are to survive.
"When we go over the numbers, 77 percent of our income is locked in at a certain rate. You're always only going to get this amount. Only 2 percent comes from municipal funding (serving the city, Wayne Township and parts of Pokagon, Silver Creek, LaGrange and Volinia townships with about 1,400 runs in 2006 with its $350,000 operating budget).
"As the youngest of all the emergency services, we're still learning how to do it right. It's also one of the most technologically advanced – and rapidly advancing – services. Things change every day. The protocols we go through totally need to be revamped" constantly. "This problem is not unique to Dowagiac. The system review found it's not our problem alone. Small services, a larger percentage of their income has to go to overhead. We recently stepped up our staffing so we could man our second truck to take more inter-facility patient transfers. Unfortunately, to cover it until I got my sixth paramedic hired, we were paying overtime. Then it doesn't pay for itself. When the money trickles in, according to our expert who did this survey for us, insurance companies put a 45-day hold on every claim before it even considers paying it. We know that Medicare and Medicaid take at least 14 days. In a normal business, you have 30 days, then you can start assessing late fees. We don't have that option. The people we do business with tell us when they're going to pay us and they decide what amount they're going to pay. We have to live with the end result."
For example, as she explained in her talk to the Democracy Club last September, when it costs the ambulance service $500 for an advanced life support transfer, Medicare reimburses $220 and Blue Cross Blue Shield pays $452. Medicaid pays $208.56.
"Unless they have secondary insurance you can go back on, that's what you're stuck claiming. You're never going to get your full amount," Evans explained. "We've talked about increasing the call rate out the door, but you can raise it all you want. it doesn't help when this is all you're going to get. We're fortunate to be considered a rural area because they pay better for rural areas. I don't believe what they're paying is realistic. I've talked to a couple of different agencies that are going to be bidding and they're in the same" predicament.
"The difference is in larger cities, you have a younger workforce," Evans said. "They have private-pay insurances that pay 100 percent. Fifty-four percent of our patients are Medicare. Another 16 percent are Medicaid. Our private pays make up a very small portion. Dowagiac's demographic is that a large portion of our population is seniors. We can't change the population and they still need the service."
Evans said this change arrived gradually. Medicare in 2000 began phasing in the current pay structure. "In the last seven years we've seen a lot of small ambulance services struggling, like Cassopolis did. It contracts with LifeCare" of Battle Creek, which is expected to be among the bidders, as is SMCAS, the Southwestern Michigan Community Ambulance Service of Niles.
"Somewhere down the line the ambulance service may not be owned by the Volunteer Fire Department," she said. "We may develop a regional ambulance authority. That's an idea that's been thrown out in the last couple of weeks: 'If we band together, we can fight off the big corporations.' "
Either way, "We just need to make sure whatever group we get in here has the same commitment to the city and this jurisdiction that we do. Years ago they talked about a countywide ambulance authority, but I don't know how that would work. Edwardsburg is an ALS (advanced life support) service, but it might not feel it needs to join an authority. It has a good tax base and a large younger work force close to Elkhart with private-pay insurance and is truly a growing community. Edwardsburg is expanding as rapidly as Granger did for a while" across the border in Indiana. "Sister Lakes, I'm not sure where it stands."
Evans spoke at Democracy Club last fall to promote a fund drive to equip a third ambulance. The $3,500 collected remains in limbo. "Chances are," she said, "we're probably going to have to repay some contributions."