Fiscal Court has tough funding decision on ambulance district
The Pendleton County Ambulance Board approached Pendleton County Fiscal Court in June of 2018 and reported they were out of funds. They asked for an advance on the taxes they would collect in the second part of 2018 to pay their June payment on the building that houses the ambulance headquarters.
Fiscal court approved, but they also set in motion plans for an extensive review to see what, if any, changes could be made in the Pendleton County Ambulance district operations and billing to improve the financial status.
Charles O’Neal was contracted to complete an audit review, and he presented his complete report and findings to the court at the caucus meeting on Tuesday, April 2.
“The buck stops at this table. Fiscal court is going to have to make a tough decision. You can 1. Fund the deficit; 2. Not fund the deficit; 3. Give a set donation and they have to figure it out,” Charles O’Neal told fiscal court about his findings from an audit of the ambulance district.
His report centered on four areas: personnel and staffing, purchasing practices, fleet management and agency policies and procedures.
Personnel and Staffing
He was very pleased with the amount of staffing for a county this size. The county has two ambulance crews working 24-hour shifts, seven days a week. He pointed out that the Advanced Life Service with a paramedic who can dispense medicine costs more than a Basic Life Service. Both of Pendleton County’s crews are ALS.
“The elephant in the room is payroll,” he told the magistrates.
With personnel being the biggest expense, he recommended the consideration of downsizing. The two 24/7 trucks could be switched to one truck on for 24/7. The other could work 16 hours with eight hours on call. This would help to eliminate overtime and would reduce expenses by 20 percent.
Studying runs per day of the week and hour of the day, the calls are pretty consistent on a daily basis. The slowest period of the day is from midnight to 6 a.m., leading to the suggestion that, that during that time, a second ambulance truck could be on call.
The second truck could be moved from an ALS truck to a BLS truck. This move was projected to reduce personnel expenses by seven percent.
“Bottom line is there is not enough revenue to sustain what you are now doing for long-term,” said O’Neal while admitting that reducing payroll might cause issues in attracting and retaining employees to work the ambulance trucks.
“The person who handles the purchasing does a very good job. He is constantly surfing and looking for better choices and challenges the present supplier to meet the lower price,” said O’Neal.
The one area that did fall under some scrutiny was the tracking of inventory control costs; however, he admitted that this tightening would produce minimal savings.
O’Neal assured the court that the fleet is in pristine condition. He informed the court they will have two paths to choose in purchasing trucks. The first is a more disposable route. The cost is $100,000 for a truck that lasts 125,000 to 150,000 is gas-operated and not four-wheel drive. The other option is a less expensive truck that will need to be remounted every four years.
Agency Policies and Procedures
“Phillip Hart is doing a good job as director, not only managing services but also works a truck,” O’Neal emphatically pointed out.
He did express concern on determining if a person was salaried or exempt concerning overtime, encouraging a decision to be made on whether an employee is salaried or hourly.
“Sometimes you get the short straw,” said O’Neal about salaried employees having to work over 40 hours in a week.
The financial issue is facing ambulance districts throughout the country as reimbursements from Medicare and Medicaid do not match the costs for a run.
The continued use of NARCAN for ambulance runs for drug overdoses receive zero reimbursement. The cost is completely absorbed by the local ambulance districts budget.
Single County-wide Ambulance District
First was a recommendation to consolidate to one ambulance district. Presently, there are three in Pendleton County. Pendleton County and Northern Pendleton are both presently taxing residents in their areas and are serving said areas.
Kenton Community has an ambulance district that taxes part of Northwest Pendleton County but has closed its ambulance services because of financial issues. There is question on whether that ambulance district can be closed and how to prevent residents in that area from paying ambulance district taxes to Kenton County without the ambulance district being opened.
Pendleton County Ambulance is covering runs in that area without receiving the tax funds to pay for the costs.
Northern Pendleton is a BSL ambulance service. When an ASL service is needed, they must call in another ambulance from either Pendleton County or from southern Campbell County.
“To commit two-thirds of the ambulance trucks in the county for one single run is not smart,” O’Neal pointed out.
According to stats from O’Neal and reported by Chief Justin Nueby, North Pendleton had 194 runs in 2018. Out of those runs, they called Pendleton County 86 times. Transport was needed for 36 of those runs. Only one of the two will receive funding on those 36 transports. Of the other 50 runs, there was no revenue for either.
Chief Neuby indicated that Northern Pendleton is considering new protocol that would “lessen stress on Pendleton County in some areas of North Pendleton.” There are other ALS services within five miles of North Pendleton while Pendleton County ambulance is 20 miles away.
Karen Nelson said the Northern Pendleton ambulance service is “life or death” for some in the district. Citing the 20-mile distance and the number of accidents on AA highway, she felt it was essential for Northern Pendleton ambulance services to remain.
In the discussion of possible consolidation, both ambulances in the county would not be housed in the Falmouth area. One would remain in Falmouth while the other would be in Butler. Not only would that positioning lessen the time response to Northern Pendleton, but it would also better serve the Northwest area of Pendleton County that is presently without an active ambulance district.
Judge Executive David Fields pointed out several times, “This body up here has to consider what is best for the whole county. We have to take in best action for everyone in the county and not just one part.”
That point was made again when it was suggested to save money by getting rid of the AirCare contract. Those from Northern Pendleton felt it was not a good use of funds when they have easy access to hospitals via AA highway.
It was pointed out that those residents in the McKinneysburg area do not have that easy access and AirCare is vital for them.
Supporters of Northern Pendleton made the point that they have never operated in the red and were financially solvent.
“We take care of ourselves in Northern Pendleton,” an unidentified supporter stated.
With a fire and ambulance district, they can assess 20 cent tax (10 cent for fire and 10 cent for ambulance) compared to Pendleton County Ambulance District only allowed to assess a 10 cent tax.
It was conceded by those with Northern Pendleton that their personnel work both fire and ambulance, and they use part of the 10 cent tax for fire to help support the personnel costs for ambulance.
While the joint fire and ambulance district benefits Northern Pendleton financially, when one is out, the other becomes out of service. If there is a fire call, the ambulance generally goes out of service and their mutual aid agreements come into play, meaning another ambulance service would handle calls to their district.
A joint fire and ambulance district for the entire county was briefly mentioned as a means to generate more revenue to help cover the financial issues.
“It should have never gotten to this point,” said Judge Fields. “We have to look at the county as a whole. This should have been tackled as a county as a whole instead of splitting the county up.”
Revenue and Billing
The Pendleton County Ambulance District was formed in 2010 to provide ambulance services in the county. It was pointed out that ambulance services for an area is not a Kentucky state requirement.
Ambulance district board member Gina Adams stated, “You cannot keep asking taxpayers for more and more.”
Magistrate Rick Mineer agreed and pointed out “that there are over 14,000 people in the county but only about 4,000 people are paying taxes.”
He further added that population studies that the fiscal court had done indicated that Pendleton County has an aging population and runs a fine line on tax rates.
“We are going to have to have a discussion on this court in the future that we may have to cut funding for things we are presently funding,” he said.
O’Neal told the court the district is not maximizing their revenue from calls and reimbursement.
“It is not the board or Phillip’s (Hart) fault. Reimbursement is only as good as your provider,” he said.
The provider is Medical Claims A assistant. They also do Northern Pendleton’s billing as well as the billing of other ambulance districts in this area.
He went on to say that the provider should provide yearly training on what staff should be documenting that would maximize reimbursement.
“Staff only documents as they are told,” he stated.
He gave an example. There are certain actions that moves a run from a BLS to an ALS run. That is a difference of $150 per run.
Hart pointed out in a follow-up call that the ambulance district has received training from MCA.
“I’ve been doing this since 1975. What you have is not sustainable without coming together. You are destined to fail,” O’Neal said. “You have to come together and come up with solutions that provide ambulance services to Pendleton County.”
Presently, the court provides the court with $168,000 in funding, including an approximate $112,000 for the building payment. The court could choose to continue funding at that level and the district would have to make it work.
Hart pointed out to the court that they have to determine the level of ambulance service they want in the county and fund it to that level. The board will have to make the decision on what services to offer based on the funding they provide.
As the court proceeds with determining the 2019-20 county budget, the ambulance question is one of many that will help shape the financial direction the county takes as well as what services residents will be provided.