HomeMy WebLinkAboutMINUTES - 02152005 - D.6 W t LLIAM B. WALKER, M.D. CONTRA COSTA
HEALTH SERVICES DIRECTOR EMERGENCY
ART LATH POP
EMS DIRECTOR MEDICAL SERVICES
JOSEPH BARGER, M.D. CONTRA COSTA
MEDICAL DIRECTOR 1340 Arnold Drive,Suite 126
HEALTH SERVICES Martinez, California
94553-1631
Ph(925)646-4690
Fax(925)646-4379
February 9, 2005
To: Board of Supervisors
From: William B. Walker, MD
Subject: Supplemental Information Related to Emergency Ambulance Services
Proposals
On February 1, 2005 your Board considered recommendations on the selection of
an emergency ambulance services provider pursuant to the Request for Proposal
issued September 7, 2004. At that meeting, your Board requested that
supplemental information be provided by American Medical Response and
StarWest Ambulance to clarify their proposals and to commit to certain additional
items. Attached are the following documents in response to your Board's request:
(1) A memorandum to AMR and StarWest requesting (a) clarification and
additional information related to each company's basic proposal, (b)
clarification and additional information related to proposed optional
services, and (c) new commitments in those areas requested by the Board.
The memorandum requested each company to complete a narrative response
and three forms to facilitate comparison of basic proposal response time
commitments (Form A), ambulance deployment plans (Form B), and the
optional services first paramedic (ambulance or QRV)response;
(2) The AMR response to the above memorandum; and
(3) The StarWest response to the above memorandum..
Both companies submitted their responses in a timely fashion as requested.
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TO: BOARD OF SUPERVISORS -.-'=•--L..,oContra
FROM: William B.Waller, MD, Director, � -#
Health Services DepartmentCosta
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February •T ---� ._ ;,�o
DATE: Feb ry 1, 205 ,
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SUBJECT: Selection of American Medical Response to County
Provide Emergency Ambulance Services Dt
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECOMMENDATION:
(1) Approve the selection of American Medical Response West(AMR)to provide ambulance services
pursuant to the Request for Proposal (RFP)issued September 7,2004 and authorize the Health
Services Director to negotiate a contract based on the RFP and the proposal submitted by AMR.
(2) Recognize that excellent proposals were submitted by both StarWest Ambulance and by AMR
reflecting a commitment by both companies in offering to provide a high level of service to the
benefit of the residents of Contra Costa County.
FISCAL IMPACT:
No General Fund impact. The cost of basic ambulance and related services to be provided under this
contract will be covered through user fees charged by the contractor. Certain optional services and
resources will be identified in the contract that may be purchased by the County at the County's sole
option. Cost of optional items, if purchased,would be covered through CSA EM-1 (Measure H) funds.
BACKGROUND:
On August 10, 2004, your Board approved a Request for Proposal for ambulance services covering those
areas of the county currently served by AMR; that is, all incorporated and unincorporated areas of the
county except for the areas of the San Ramon valley and the Moraga-Orinda Fire Protection Districts,
where the respective fire district provides ambulance service. The RFP set forth general standards for
service, specific response time and staffing standards for each of five zones, provided for a proposal
scoring and selection process, and provided for the pricing of certain optional items not a part of the basic
system design plan. Ambulance companies with membership in the California Ambulance Association or
the American Ambulance Association were notified of the RFP availability. Copies of the RFP were
distributed to a number of ambulance companies that had expressed interest in providing services in
Contra Costa County. The RFP and other documents of interest to potential bidders were placed on the
County EMS web site. The RFP was officially released on September 7, 2004.
CONTINUED ON ATTACHMENT: X YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURES):
—-----------------------------------------_------------------—-------—-------"------_-----------------
___�_�.�._____�___.�.�_M.
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ACTION OF BOARD ON APPROVE AS RECOMMENDED OTHER
VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE
AND CORRECT COPY OF AN ACTION TAKEN
UNANIMOUS(ABSENT �� } AND ENTERED ON THE MINUTES OF THE
BOARD OF SUPERVISORS ON THE DATE
AYES: NOES: SHOWN.
ABSENT: ABSTAIN:
ATTESTED v
JOHN SWEETEN,CXj1RK OF THE BOARD OF
SUPERVISORS AN COUNTY ADMINISTRATOR
Originating Department: Emergency Medical Services 646-4690
cc: County Administrator
County Counsel
Health Services Administration
Emergency Medical Services
Contra Costa County Fire Chiefs Association
Each Fire Chief
BY EPUTY
A proposers conference was held on September 22nd to answer questions prospective bidders might have
regarding the RFP and the County's EMS system. Representatives of nine ambulance companies attended
the proposers conference, including representatives from AMR and from StarWest. In response to a
request made at the proposers conference,EMS made available to prospective bidders a database
containing ambulance
dispatch records for a one-year period for the area to be served.
Two proposals were received by the November 4th submission deadline, one from StarWest Associates,
LLC, doing business as StarWest Ambulance—Contra Costa, Inc., and one from American Medical
Response West doing business as American Medical Response. The proposals were publicly opened and
made publicly available through placement on the Contra Costa EMS web site. There were no late
submissions of proposals. StarWest Ambulance—Contra Costa is a new company under control of
StarWest Associates, LLC, an Arizona company that provides emergency paramedic ambulance services
through its subsidiary Southwest Ambulance-Las Vegas in Clark County,Nevada. American Medical
Response West is the County's existing emergency paramedic ambulance provider and is a subsidiary of
Colorado-based American Medical Response, Inc., a wholly owned subsidiary of Laidlaw International,
Inc. American Medical Response is the primary emergency paramedic ambulance provider in a number of
Bay area and other California counties and provides services in many other states. (Note: On December
6, 2004, Laidlaw announced a definitive agreement to sell AMR and AMR's sister company EmCare to
Onyx Partners, a limited partnership company including AMR and EmCare Senior Management and Onyx
Corporation.)
Proposal Review Process and Preliminary Recommendation
The proposal review process was conducted by Richard Keller of Fitch and Associates, EMS's consultant
on the EMS system design and RFP development, in accordance with the scoring and evaluation criteria
set forth in the RFP. The actual scoring of the proposals was conducted by a 10-member Proposal Review
Panel meeting over a three-day period November 15'h, le and 17th. Representation on the Panel was set
by the Board of Supervisors to include representatives selected by the County Public Managers
Association,the County Police Chiefs Association,the County Fire Chiefs Association, Firefighters Local
1230, SEIU Local 250,the Hospital Council, and persons appointed by the Health Services Director to
include an emergency physician from within Contra Costa County, an emergency nurse from out of
county, a local EMS agency director from out of county,, and a consumer member of the County
Emergency Medical Care Committee. All Panel members received copies of the two proposals in advance
of the first Panel meeting and all participated in all three days of the Panel review. EMS staff served as a
resource to the Panel. The accounting firm of Caporicci and Larson was engaged to observe the process
and to compile scores. Only the ten Panel members participated in the actual scoring.
The Review Panel rated proposals "yes"/"no"on each of five qualifying criteria and then scored the
proposals on 61 different factors covering commitment to clinical quality, commitment to employees,
operations management, commitment to the EMS system and community, management and
administration, and organization requirements. Each factor was discussed and individually scored.
Panelists were instructed to score the better proposal the full number of points and the other proposal
either an equal or lesser number of points. Scores for 10 pricing factors were calculated by formula with
the lower priced proposal receiving the maximum points and the higher priced proposal receiving a
proportionately lower score. Panelist completed score sheets for one group of factors before moving on to
the next. Altogether,the ten panelist completed 15 different score sheets (one for each group of factors).
Score sheets were collected by the independent accountant after that group of factors was discussed and
scored. After preliminary scoring was completed,the panelists heard oral presentations from the
proposers. Following the oral presentations,panelists were given an opportunity to discuss each of the
scoring factors and to make adjustments to their scoring. Summary tallies were not made prior to
completion of the review process.
The result of the Review Panel process was that both proposals were judged by each of the panelists to
meet all qualifying factors, and the two proposals received tie median scores of 1,320 out of 1,400
possible points. Following the process established in the RFP,the Health Services Director announced a
preliminary recommendation and provided an opportunity for protest. Given the closeness of the two
proposals,the Health Services Director's preliminary recommendation was to retain the services of the
County's incumbent provider American Medical Response.
StarWest Protest
StarWest Ambulance filed a timely protest with the Health Services Director raising a number of issues,
which will be discussed below. AMR was provided an opportunity to comment on the issues raised by
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StarWest, and Fitch and Associates was asked to prepare consultant's comments on the issues raised in
StarWest's protest. Following consideration of the issues raised by StarWest in its initial protest and
subsequent communications and review of AMR's comments,the Caporicci &Larson Review Panel
scoring report, and the Fitch& Associates analysis of the protest issues, we have concluded that no
substantive issues have been raised that would change the preliminary recommendation on the selection of
American Medical Response.
The issues raised in the StarWest protest and the staff determination on these issues are as follows:
Issue #1:AMR proposed a$198 "treat and no transport" charge compared to Star West's proposal of
no charge for "treat and no transport. " StarWest contends that the Review Panel must not have
realized that this charge would or could be levied on all calls in which the ambulance arrives on scene
but does not transport a patient to the hospital and would result in annual patient charges of$2.6
million.
Determination on Issue#1: All patient charges, including the "treat and no transport charge" were
appropriately considered in the proposal scoring. The "treat and no transport" charge applies only
when paramedic treatment is performed on a patient who subsequently declines transport. The
formula developed by Fitch&Associates for scoring the proposals used an assumption that 5.0
percent of the patients billed(about 2,666 annually)would have a"treat and no transport"charge.
AMR reports that current billing experience in Contra Costa County shows that only 0.2 percent of
patients (fewer than 100 annually) receive this charge.
Issue #2: The RFP "Optional Services Price List" asks the proposer to identify a charge to the County
should the County opt to include a 9:59190%paramedic (ambulance or QR P) response standard in the
urban/suburban areas of the East Contra Costa Fire Protection District (Ambulance Response Zone E).
Star West proposed to provide this at no charge. AMR submitted a charge of$1,258,000 annually to
include this as a required standard.
Determination on Issue #2. The RFP clearly identified that"Optional Services"were not to be
considered in the scoring of proposals. These items were considered informational only. The RFP
requires that the ambulance service provide three Quick Response Vehicles(QRVs) in Zone E at no
cost to the County in addition to meeting the 11:59 ambulance response time established for all
zones with first responder paramedic service. This is identical to the Zone E requirement that went
into effect September 1, 2004 in the existing AMR contract. Analysis of dispatch data demonstrates
that the combination of the 11:59 ambulance response time requirement and the requirement for the
provision of three paramedic-staffed QRVs in Zone E does, in fact, result in paramedic response
times of under 10 minutes 90% of the time for the urban and suburban areas of Zone E. Therefore,
there is no demonstrated benefit for the County to purchase this optional service.
AMR erroneously interpreted the RFP optional pricing for 9:59/90%paramedic response time in
Zone E to include all areas of Zone E. rather than the urban/suburban areas of Zone E. The
urban/suburban areas of Zone E are limited to Brentwood and Oakley. Bethel Island, Byron, and
Discovery Bay are identified in the RFP as designated rural areas.
Issue #3: AMR provided misleading information regarding the proposed plan to provide six Supplemental
Transport Ambulance Resources (STAR cars) at fire stations in the county to be used by fire in defined
emergency situations. AMR's proposal gives the impression that agreements have been reached between
AMR and the fire services regarding these STAR cars when, in fact, no such agreements are in place.
Determination on Issue#3. Information provided by AMR regarding STAR cars does not appear to
have been misleading. The placement of equipped ambulance units at fire stations for use by fire in
a disaster was one of the requests made by Firefighters Local 1230 and SEIU Local 250 in their joint
letter of May 14, 2005. The letter was included in the RFP, and the Optional Services Price List
requested pricing for such reserve ambulances to be positioned at fire stations. AMR provided
requested pricing,but also included six such units in its basic proposal at no charge. These resources
are not intended for regular use. AMR has stated that STAR cars are for use in accordance with
whatever criteria may be developed by County. Furthermore, AMR has stated its willingness to
negotiate provision of other services in lieu of STAR cars in the event that fire services do not agree
to the placement of STAR cars.
Issue #4 : AMR's proposal identified American Medical Response West as a wholly owned subsidiary of
American Medical Response, Inc., but failed to state that Laidlaw International was the ultimate parent.
Determination on Issue#4: AMR met the requirements of RFP with respect to identification of
ownership and organizations structure. AMR did seek clarification from the County prior to
submitting its proposal as to the level of the organization for which financial information was
required. The County responded, "If the company is diversified in other business lines,the County
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desires the `parent' to be the entity holding its medical transportation operations." Further, audited
financial statements for AMR West and AMR included in the AMR proposal clearly identify AMR
as a wholly owned subsidiary of Laidlaw International.
Issue #4: AMR's proposal failed to disclose the sale-in-progress of AMR, Inc. by Laidlaw International to
Onex Partners, LP in violation of the RFP requirement to provide organizational ownership and legal
structure.
Determination on Issue#5: AMR's proposal fully met the requirements of the RFP with respect to
the statement of organization ownership and legal structure. The RFP did not address disclosure of a
non-finalized sale. AMR did formally notify the County on December 6, 2004, the date of the public
announcement, of the agreement between Laidlaw and Onex Partners for the sale of AMR. This
notification was prior to the Health Service Director's preliminary recommendation on the AMR
selection. AMR's position is that disclosure of intended sale prior to the public announcement was
precluded by Securities and Exchange regulations. While there may be some contention that Contra
Costa County could have been notified prior to the public announcement, it is not likely that such
disclosure would have changed the outcome of the selection process. Ownership and financial
factors were not considered in scoring, but were qualifying only. It was well known that Laidlaw
International had been seeking a purchaser for AMR for some time, and we are aware of no
information that would have disqualified the AMR proposal had the County been advised of the sale
prior to the Review Panel process.
Final Recommendation to Board of Supervisors for Selection of AMR
In making a final recommendation to the Board of Supervisors for the selection of AMR to provide
emergency ambulance services over the next five to nine years,the following factors were considered:
(1) History of service to the community.
AMR, or its predecessor organization Regional Ambulance, has been providing emergency
ambulance service under contract with Contra Costa County continuously since 1983. During
4.
this period AMR has demonstrated an excellent record of meeting performance requirements,
providing community service, and cooperating with an evolving EMS system.
(2) Strength of clinical quality and medical oversight.
AMR's proposal demonstrates a stronger commitment to clinical quality. Of particular
importance are the identification of three full-time quality improvement positions and the local
availability of a physician medical director. Dr. Gary Tamkin, a resident of Lafayette, an
attending physician at Highland General Hospital and Assistant Clinical Professor of Emergency
Medicine at U.C. San Francisco, has served as AMR's medical director for Contra Costa and
Alameda Counties for over three years.
(3) Response time commitment.
While both AMR and StarWest have offered specific response time enhancements over the basic
RFP requirements in their core proposals,AMR's initial deployment plan places 4,024
paramedic ambulance unit/hours per week in the county to respond to 9-1-1 calls compared to
only 2,980 for StarWest. AMR currently deploys 3,238 paramedic ambulance unit/hours per
week dedicated to 9-1-1 response. AMR's deployment plan reflects experience with the
demands of the Contra Costa EMS system,both existing and as proposed. While the County
ambulance contract is based on level of performance, not level of effort, AMR has agreed to
maintain the proposed 4,024 unit hours as a minimum for at least the first six months of the
contract period.
The StarWest proposal to meet a 10-minute/90%response standard in the urban/suburban areas
of Zone D (Antioch/Pittsburg/Bay Point) and Zone E (Brentwood/Antioch), while appearing to
provide a 2-minute advantage over the 11:59/90%RFP requirement, fails to recognize that
demographics of these zones result in actual response times equaling or approaching 10-
minute/90%even when the standard is set at 11:59/90%. This factor was recognized in the 2004
Fitch&Associates Report finding that extending response times in Zone E would not produce a
savings in unit-hours since existing ambulance deployment could not realistically be reduced
without compromising the ability to cover the zone. AMR's proposal, on the other hand,
contains a modest improvement in the urban/suburban response times for Zones B, C, D, and E
(11:45/90% in place of the RFP requirement of 11:59/90%) and a significant improvement for
the two rural communities of Bethel Island and Discovery Bay(16:45/90% in place of the RFP
requirement of 20:00/90%). Table 1, attached, compares AMR's existing response time
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compliance by Zone and community with the RFP requirement, with AMR's proposed standard,
and with StarWest's proposed standard. Also shown in Table 1 is the provision in each
community for paramedic first response—fire, QRV, fire and QRV, or no paramedic first
response..
(4) Capacity for disaster response.
As the primary provider of emergency ambulance services in several Bay area and other northern
California counties,AMR has significant resources that can be committed to a disaster or other
major medical incident. While a system of medical mutual aid exists in California through
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which ambulance resources can be obtained from other counties regardless of provider,
experience in events such as the Martinez fire of 2004, which threatened to force evacuation of
the Contra Costa Regional Medical Center, and various refinery incidents have demonstrated the
quick response of AMR in mustering large numbers of resources without the need to go through
a formal mutual aid request. For example, in response to the Martinez fire, AMR was able
proactively to muster ambulance resources from Alameda, Santa Clara, and Sacramento
Counties to stage at locations where they could quickly respond if requested to evacuate the
hospital. This was provided without cost to the County and without disruption to services in
adjacent counties.
(5) Additional community service commitment.
An important requirement of the RFP was a demonstration of commitment to community
education and community health improvement. While both AMR and StarWest made significant
commitments in this area,the AMR proposal was stronger in this area. For example, AMR
committed to a full-time community outreach coordinator and committed to the placement of 15
automatic electronic defibrillators (AEDs) each year of the contract in community locations as a
part of the County Public Access Defibrillator program.
(6) Patient charges.
Based upon the composite formula developed by Fitch&Associates for comparison of patient
charges, StarWest's proposed charges average $1,014.58 compared to $1,046.15 for AMR. This
difference in patient charges of about three percent was not judged significant given the
increased service levels proposed by AMR. The proposed AMR patient charges do not reflect
any increase over the patient charges provided in the existing AMR contract
StarWest Proposal
While recommending selection of the AMR proposal, staff wishes to recognize the excellent job done by
StarWest in preparing that firm's proposal and to acknowledge the benefit to the residents of Contra Costa
County that will result from the strong competition provided by StarWest.
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