**LEAD STORY**
This is Part Two of a series that we are entitling, "The Changing Face Of The Fire Service." In Part One we learned how the Boston Fire Department is thinking about altering its mission, a bit, in the face of budgetary constraints.
It is now a fact that EMS services comprise the bulk of department responses. For example, Phoenix, Arizona, in 1991 responded to 105,754 emergencies of which 76 percent were for medical emergencies.
Tradition-bound fire departments in the United States are going to have to adjust their missions a bit to reflect this new reality. So far, very few have done so since this article was written in December of 1994. Some departments that have tried to make the adjustment have met some resistance by old-timers in the department who see their job only to fight fires.
The author has studied and has extensive files on most major fire departments in the U.S. The only department that I have seen to fully embrace the future mission of the fire service has been the Phoenix, Arizona, Fire Department that is led by Chief Alan V. Brunacini. Brunacini is seen as probably the most innovative fire chief in the world today and his department reflects that.
The concept of the Paramedic-Engine, an engine company with at least two paramedic-firefighters aboard is the future. While not new, there are still only a few departments, today, implementing this concept. Phoenix uses the concept extensively and it works very well.
In this second and final part we will learn how other departments are looking toward EMS to justify and in, some cases, increase their budgets.
Regular readers to this publication who read Gary Ludwig's column will recognize the debate and competition between EMS services provided by fire departments and private ambulance companies.
In the past two years, dozens of fire departments nationwide have tried to grab a piece of the ambulance and paramedic business before its devoured by a merger-crazed health care industry.
For the firefighters, it's a matter of necessity. Thanks to more than two decades of wildly successful fire prevention programs, firefighters spend less time fighting fires and much more trying to keep city councils from slashing their budgets.
Since 1992, four monolithic corporations have emerged from either of investment capital, swallowed 75 of the nation's biggest local ambulance companies in 33 states and positioned themselves as cheaper alternatives to public paramedics.
At least once a week, one of the behemoths buys a local ambulance company. In two years, they have taken control of one quarter of what analysts conservatively estimate to be a $4 billion business.
The private sector, once dominated by moonlighting morticians who slapped flashing red lights on their hearses, now uses satellites to position its ambulances, Wall Street to bankroll its acquisitions and courts and local governments to fight bruising turf battles with a firefighting lobby trying desperately to preserve its place in American culture -- not to mention city budgets.
"Fire departments nationwide have made it clear the only way they're going to remain in operation is if they go into the ambulance business," said Dan Smiley, chief deputy director of California's Emergency Medical Services Authority. "This is survival for both sides, public and private," Smiley said. "Only one can get the call, and they both want it."
What they want most is the Medicaid, Medicare and private health insurance reimbursements for a trip to the hospital. Both also want to expand into EMS' logical extension: using those well-equipped vehicles to deliver non-emergency care for profit.
"You're going to see a lot of change in EMS. You're going to see them provide more diabetes screening, medication delivery for the elderly, vaccinations," said Dr. Scott Zietlow, medical transportation chief for the Mayo Clinic.
A new nationwide effort by the firefighters to seize EMS from private ambulance companies is being encouraged by national lobby groups who fear the private ambulance industry is getting too big, too powerful and, most of all, too efficient to withstand.
"What rang our bell is there seemed to be a concerted effort by several large EMS companies in this country to dominate the industry," said Doug Brown, top lobbyist for the International Association of Fire Chiefs. "If they can knock away EMS from the fire service, they will knock away the fire department."
A brief tour of the battlefield:
* Private ambulance companies have gone to court in at least eight California communities in the past two years seeking to stop the local fire department from taking over the paramedic business.
* In September, Bacon Raton, Florida, fired its private ambulance company so the fire department could get the insurance reimbursements.
* Firefighters are livid in Louisiana, where a regional ambulance company is advertising a "311" emergency service to compete with the publicly staffed 911.
* In Fresno, California, last July, the city decided its public paramedics are superfluous to the private sector and eliminated their budget.
* Ambulance giant American Medical Response, Inc., earlier this year tried to buy the ambulance company serving Rochester, Minnesota, home of the Mayo Clinic. Mortified Mayo worried about losing its local ambulance provider to a giant national firm, stepped in and matched the bid.
* In March, Portland, Oregon, narrowly rejected this year a measure to let firefighters handle ambulance service in life- threatening cases.
* In Albany, New York, the common council in September settled a fued by giving firefighters a cut of ambulance company insurance reimbursements.
Experts say it's unclear, yet doubtful, whether the turmult has caused any sharp rise in deaths. If anything, the competition has led to vast improvements in response times.
Still EMS in general is a muddled mix of public, private, volunteer, hospital-based and hybrid systems that veer crazily in quality nationwide from the good to the bad to the extremely ugly.
"There is no uniformity in this country. In some places, you can dial 911 in New York state and get an ambulance that was illegal in Arkansas in 1973," said Jack Stout, who has designed private systems for Kansas City, Fort Worth, Tulsa, and the former Israeli-occupied West Bank.
It's still far from decided whether EMS will be dominated by the health care industry or the public safety sector, but it's clear that the private side is creeping up on the guys in the red hats and galoshes.
Among the nation's 100 most-populous cities, the portion relying on the fire department for EMS has dropped from 48 percent in 1981 to 40 percent last year, according to the industry's Journal of Emergency Medical Services.
Cities relying solely on the private sector rose from 17 percent to 19 percent, and those using a combination of both went from 6 percent to 15 percent. The rest used volunteer services, hospital paramedics or a public agency unaffiliated with the fire department.
Firefighters now typically spend only about 20 percent of their time fighting fires, mainly because of better building construction, tougher codes and mandatory smoke detectors.
Civilian fire deaths fell from 6,015 in 1977 to 3,720 last year, the National Fire Protection Association says. Fire departments responded to 2.5 million fires in 1982 and only 1.9 million last year.
"Fire departments are waking up. They're saying 'Our future's in EMS, or else we're going to be phased out,'" said Dr. Paul Pepe, the highly-respected head of Houston's Emergency Medical Services.
Perhaps the most bitter case is in Sacramento, where firefighters won a lawsuit last year allowing them to compete with private ambulance companies. Now the city is considering taking over the entire market.
Its main competitor, Boston-based American Medical Response, has filed a federal antitrust suit. AMR chief executive officer Paul Verrochi, who previously helped consolidate national sanitation and environmental services companies before moving into ambulances two years ago, said he isn't trying to put firefighters out of work.
He said it's clear, however, that "firefighters are trying to expand their scope of business in order to protect their jobs. The position we take is we can co-exist with a fire department," he said. "Where we are having battles is where the firefighters say, 'Look, we want all the ambulance service."
With $350 million in annual revenues and dominant stakes in 17 states, AMR is the biggest of the four national ambulance companies that have transformed the industry. Two others formed within the past two years. Careline of Irvine, California and MedTrans, a division of Laidlaw, a $2 billion Ontario transportation company.
Rounding out the big four is Rural-Metro of Scottsdale, Arizona, a regional ambulance company that went national last year. It already runs the fire department in Scottsdale -- the traditional firefighter's worst nightmare.
The merger mania in the ambulance business has coincided with the trend toward managed care in the health industry. The theory is that being big and regional is more cost-effective than being small and local.
The belief that President Clinton would get universal health coverage -- a concept tabled by Congress -- also fueled the acquistion fever. Many EMS providers -- normally stiffed on 25 percent of their bills -- believed that meant the federal government would pick up ambulance bills.
The whole trend toward regional health care has threatened to take EMS out of the hands of local communities. "Once the managed care providers get control of a region, they are going to force everyone to work together efficiently," said Tom Scott, director of the Emergency Care Information Center, a consultant group in Carlsbad, California. "They don't want to deal with several fire departments and ambulance companies."
The ambulance companies are devouring each other so quickly that the American Ambulance Association, the industry's private trade group, has lost count of the transactions. "The modus operandi of these companies is to acquire and consolidate," said Lehman Brothers analyst Jefferey Kessler in New York. "None of them is done doing deals."
Though the big ambulance companies say they have no desire to put the fire departments out of the paramedic business, Fire Chiefs' Association lobbyist Brown doesn't buy it. "I would say firefighters do about 25 percent of the medical transport nationwide. To ambulance companies, that's market share," he said.
Firefighters are clearly rattled. Like the cowboy and the cop, the firefighter is an American icon. "Hey, we do rescue stuff," Brown said. "We get your cat out of the tree."
(c) EmergencyNet News Service, 1996, All Rights Reserved.