1 3 9 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 KERR COUNTY COMMISSIONERS COURT and KERRVILLE CITY COUNCIL EMS Workshop Wednesday, July 13, 2005 9:00 a.m. Commissioners' Courtroom Kerr County Courthouse Kerrville, Texas Kerr County Commissioners Court: PAT TINLEY, Kerr County Judge H.A. "BUSTER" BALDW7N, Commissioner Pct. 1 WILLIAM "BILL" WILLIAMS, Commissioner Pct. 2 JONATHAN LETZ, Commissioner Pct. 3 DAVE NICHOLSON, Commissioner Pct. 9 Kerrville City Council: DAVID WAMPLER, Councilperson, Place 3 DUN DAMS, Interim City Manager 0 0 2 1 2 3 4 5 E 7 8 9 10 11 12 13 14 15 16 17 18 19 L V 21 22 23 24 25 On Wednesday, July 13, 2005, at 9:00 a.m., a joint workshop meeting of the Kerr County Commissioners Court was held in the Commissioners' Courtroom, Kerr County Courthouse, Kerrville, Texas, and the following proceedings were had in open court: P R O C E E D I N G S COMMISSIONER BALDWIN: Good morning. Thank you guys for coming over. This is our EMS workshop, and appreciate the acting City Manager coming, and Mr. Wampler, appreciate you coming back. And we have met previously, I believe sometime in May. Let the record reflect the County Judge is getting here a little bit late. MS. DAMS: Good morning. JUDGE TINLEY: My apologies, gentlemen. COMMISSIONER BALDWIN: Apologies accepted. But we -- the City Manager and Mr. Wampler and I went over this document that I have provided for y'all, and as -- and explained it to me, and as I attempted to visit around here about it, just more and more questions kept popping up, and I thought it would be -- the best way to do this thing is for to us sit down around the table and just work through it all, So, sir, take your liberty. MS. DAMS: Appreciate it. I hope you have also had the opportunity to look at the answers that we provided a couple of weeks ago, I guess, to a set of 7 13 US lwk 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Z1 22 23 G `f 25 questions from Commissioner Baldwin, and also, then, Judge Tinley, COMMISSIONER WILLIAMS: Mm-hmm. MS. DAMS: Two different sets. So -- and what -- Buster, what I guess I propose to do this morning is just run through this letter that was sent over in May by Ron Patterson -- or drafted by Ron Patterson, and I think Ron and David delivered it over here. COMMISSIONER BALDWIN; Correct. MS. DAMS: And starting with the first attachment, Attachment 1, and just qo through those numbers a little bit and make sure that everybody understands them. And for our purposes this morning, I'm going to just disregard that lefthand column, the column that's titled, "No Subsidy," because that -- that's really not appropriate in that the City is already subsidizing the operation. So, let's start with the middle column, which represents this fiscal year's budget, and inc]udes a $129,000 supplement by the City. As y'all note, we are beginning the year with a -- or began the year with a $79,000 deficit, and we estimated revenues of $1,659,070. We had a -- a transfer into the operation, and, quite frankly, I can't remember what that -- what that is, the $578. Then the -- the next four numbers are existing payments that are made by the City and the County. 7-13-05 jwk 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Y'all know, I'm sure, that we split the payment along with the City of Ingram. They pay a little stipend also to our medical director, and his responsibility is to oversee the protocols and help the EMT's and paramedics when they have questions or need help, so I believe we pay him something like $20,000 a year for that part-time service. The next two numbers, again, are shared. That's the lease on the facility out on Coronado Street, the $12,000. Then that 129, as I mentioned, is the City subsidy for this fiscal year. And then the last number there is the $10,780 which the County pays to our EMS Director to serve as the County's director or manager of the First Responder program. Now, my understanding is that that number was determined a few years ago and represents 25 percent of what was then his salary. Does that sound right? COMMISSIONER BALDWIN: Yes, sir. MS. DAMS: Okay. All right. COMMISSIONER WILLIAMS: What is the salary now? Do you know? MR. WAMPLER; Weli, the 25 percent number equals about $16,000 now, so whatever 16 times 4 is. So, in other words, his salary's gone up, but the subsidy stayed about the same. COMMISSIONER LETZ; About 64,000. MS. DAMS: It's in one of these attachments, ~-is-os jwx 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 29 25 Bill. I can't remember off the top of my head. COMMISSIONER WILLIAMS: We'll get there. MS. DAMS: Okay. But David`s right, that since that was conr_eived, over the years, that increase is -- or that 2~ percent has increased by about $6,000. Anyway, that gives us total funds available, as you see there, the one million, 750. The operating expenditures are listed there, and we're projecting an ending balance, again, of $11,222 deficit. The 5 percent fund balance requirement, the City has a policy whereby we try to provide a fund balance of 5 percent on all of our funds. And the last several years in the EMS fund, we have not been able to achieve that, and it does not appear that we're going to be able to do it this year either. That fund balance is really kind of an emergency fund in the event that something happens that's unforeseen, and that money is a contingency and is available -- COMMISSIONER LETZ: Question, just on how the City operates on that. Do you all have -- you're all set up with dedicated funds so that the -- like, if you need money, you can't go in for -- say EMS, y'all can't go into the -- you don't have a general fund? Or you have a general fund and you have all these other funds? I mean, we have certain -- we have a general fund, then we have certain dedicated funds that can only be used for certain purposes. 7-13-OS iwk 6 1 2 3 4 5 6 7 8 9 10 11 12 -~- 13 14 15 16 17 18 19 20 21 22 23 24 25 MS. DAMS: As we do, Jonathan. I don't moved from within that -- that general fund. Again, my understanding is there's -- there is a policy -- and I'm not sure, David, whether it's written or it's just kind of an administrative policy -- that the department heads can, within their operating department, move moneys around, as long as the bottom line is not changed. Then the City Manager and the Council -- well, the City Manager might do some interdepartmental transfers, but the Council needs to approve any interfund movement. So, there are dedicated funds and some restricted funds, and we have a couple of enterprise funds. But the biggest fund -- the two biggest funds are the general fund and the water and sewer fund. COMMISSIONER LETZ: I guess the reason for my question is that, I mean, we have a -- a policy, but it really applies to the -- to the -- our funds are divided up, our dedicated funds, and a certain tax rate is attributed to each one, and that's -- fees go into it or some source of revenue that you can track. And we keep a general reserve fund of a certain amount, of -- you know, our policy is no less than 25 percent of our operating budget, essentially. And I was just wondering how you do it, because if you -- it seems that if you -- if we went by, you know, the Treasurer ~ 1"i-OS ~wk. 7 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 needed to keep 5 percent and Rusty needed to keep 5 percent and everyone needed to keep 5 percent, that you could end up with a lot more money in that fund than you necessarily need. I mean, I think -- so we just have a general policy, we keep 25 percent. MR. WAMPLER: We have it broken out by fund, by budget. So, rather than having a single contingency fund that's fed into by all the different budgets, we have a S percent contingency policy that is actually a written policy. Now, what Don was saying in terms of the flexibility within a given fund, the department heads do have some flexibility, but for the interfund transfers, that requires Council action to make that happen. COMMISSIONER LETZ: Do y'all budget for this 5 percent? MR. WAMPLER: Yes. COMMISSIONER LETZ: So, you -- every department has a 5 percent contingency? MR. WAMPLER: Yes. COMMISSIONER LETZ: That's different than our reserve fund. MR. WAMPLER: And, again, just to be clear, that 5 percent contingency is a policy and it's a goal. In this case, as you can see, we're not there. So, in other words, if the numbers don't add up, we can't get Lhere. I 7-13-u5 jwr 8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 mean, you know, we're not in violation, but it's actually a policy -- a written policy that says that we will make every effort to get there. COMMISSIONER LETZ: Okay. COMMISSIONER W7LLIAMS: Is EMS, by your definition, an enterprise fund, or is it different? MS. DAMS: No, it is not. I think it used to be. MR. WAMPLER: It used to be. MS. DAMS: Yeah. And, again, I think it was like in 2001-2002 time frame when the operation started losing money essentially, and we think most of that is attributable to the fact of the Medicare -- what we call disallowables. And, you know, they only pay a certain part of that. Then, at that time, the -- the operation was moved from an enterprise fund into the general fund. MR. WAMPLER: An enterprise fund, Bill, would be like the water and sewer fund. COMMISSIONER WILLIAMS: Yeah. MR. WAMPLER: As an e::ample, we try to run -- I say "we." The EMS budget had been run as an enterprise fund for 10 or 15 years, and was one of the few EMS services -- municipal EMS services in the state that was self-sufficient for all of that time. But, as Don said, as revenues started to decline, primarily due to Medicaid -- or 7-13 ~~5 jwk 9 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Medicare disallowables, you know, we moved it from effectively an enterprise fund and had to start subsidizing ~t Prom our general fund to -- to maintain it. COMMISSIONER. LETZ: And let me go back just a little bit so y'all understand why I'm asking the question. As I'm looking at this, it appears that somewhere in the -- in these numbers up here for the next year, the County is being asked to help get to that 5 percent fund balance. I think that's a legitimate -- a fair way to do it if we're Fifty-fifty partners, but we're not here. This is a contracted basis. I think that the City should be responsible for keeping the fund balance wherever they want it, and we should just pay for services. I don't know why I the County should have to pay for that 5 percent. That's -- and maybe I just don't understand how it all works yet, but that's just so y'all understand why I asked that question. COMMISSIONER BALDWIN: That's a legitimate question. It could be discussed. COMMISSIONER LETZ: Sure. I mean, I'm not saying -- COMMISSIONER BALDWIN: Good discussion. COMMISSIONER LETZ: Okay. We can go ahead and probably go through it. MS. DAMS: All right. The -- the final column that we see that is shown there on the right-hand ~-is-nom ~wx 10 1 °-~ 2 3 4 5 6 7 8 9 10 11 12 ...- 13 14 15 16 17 18 19 20 21 22 23 -" 2 4 25 side, again, we're talking about beginning the year with that $11,000 deficit, so we're not carrying forward the fund balance into next year. We did project a 2 percent increase in revenues, as you'll see. The -- the shared cost on the same. We are anticipating an increase in the City's subsidy up to 136,837, projecting a County subsidy of 136,837, and then also a subsidy for a half of a -- of an ambulance. So, the 37,500, if you add that, is obviously the $75,000. That represents about half of one new ambulance, and you'll see down in the expenditures, we have that as $150,000. The reason that we only need to subsidize a half of that is that the revenue generated from -- from non-emergency transfers is sufficient enough to where it can pay for the other half of the ambulance. Zn other words, we have a -- a little bit of overage in that particular operation. Then we show, again, the First Responder, 10,780 being the County's responsibility, giving total funds available of 2,075,063. Again, in the operating expenses, we have estimated a 4 percent increase in just our regular operating budget. We do propose to replace one of the ambulances for $150,000. Then we have the transfer out, and I believe that is a payment that is made for two dispatchers in the police department. So, here is one of these kind of interfund transfers, so that that represents the cost of -- 7-13-OS jwk 11 1 2 3 4 5 6 7 8 9 10 11 12 13 19 15 16 17 18 19 20 21 22 23 24 25 of the communication and dispatching service that the EMS uses. COMMISSIONER WILLIAMS: Would that not fall under your agreement with 9-1-1 for dispatching? MS. DAMS: We -- Bill, we do our -- our own dispatching. The dispatchers at the police department dispatch our police, fire, and EMS services. The only thing that I'm -- I'm aware of on -- on the 9-1-1 is the -- the money that's collected, I believe, through the telephone company, if memory serves me, and -- and then that was used to purchase some of the equipment, but not any of the operational costs. COMMISSIONER WILLIAMS: There's no 9-1-1 money that goes in for dispatching operations? MS. DAMS: I don't -- I don't think so. COMMISSIONER BALDWIN: Yeah, there is. JUDGE TINLEY: There's $36,000 a year -- MR. DAMS: Okay. JUDGE TINLEY: -- over the last contract that I saw that's paid for. MR. DAMS: I'm sorry, I don't know. I don't know. COMMISSIONER BALDWIN: And that's almost a dispatcher. MR. DAMS: Yeah. Yeah. ~-13-05 jwk 12 1 2 3 9 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 COMMISSIONER BALDWIN: But that's correct with his figure. JUDGE TINLEY: That was the last contract I saw. I don't know whether that had been renegotiated since I saw that. MR. DAMS: I don't think so. COMMISSIONER BALDWIN: I think that's supposed to go toward a salary and some certain equipment and those kinds of things, 36,000. JUDGE TINLEY: It was a contract fee for City of Kerrville Police Department to operate dispatch operations for the PSAP for the 9-1-1 system. COMMISSIONER WILLIAMS: That's the way I recall it. MS. DAMS: Okay. Anyway, going down, you see we have, again, that -- that 5 percent fund balance, and that then is -- is projected balance for overall next year of a dollar. And I will strongly recommend to the Council that that balance be split with the County at the end of the fiscal year, so we'll each end up with 50 cents. (Laughter.) I'm sorry. No -- no levity here this morning. All right. Anyway -- COMMISSIONER WILLIAMS: A little bit. MS. DAMS: -- what this means is that the total cost with this budget to the County for all of the ~-i3-ns ~w~ 13 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 77 23 24 25 services would be 200,157, and that would include 189,000 for the EMS, and then the 10,780 for the First Responder, and those numbers are in the very last sentence of the footnote down there. Kind of -- that's kind of the bottom line. But -- and it does represent the City and the County splitting the deficit equally on a fifty-fifty basis. And the way the subsidy was arrived at was by taking the projected revenue and the deficit, adding in the costs that are already shared, and then deducting from that the expenditures and the fund balance, then simply dividing that by two, and that's how we arrived at the 174,333 -- or 337, which is half of -- of the projected deficit. Any -- any questions on that schedule or the proposed budget? Attachment 2 -- JUDGE TINLEY: Excuse me, Mr. Davis. MS. DAVIS: Okay. JUDGE TINLEY: The bottom line of what I'm hearing is the $200,157 is your calculation of what you believe to be Kerr County's fair share of all EMS costs, including First Responder and medical director and emergency services? MS. DAVIS: Yes, sir. JUDGE TINLEY: The whole gamut of -- MS. DAMS: Yes, sir. JUDGE TINLEY: Okay. ~-is-os -w~; 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 MS. DAMS: Yes, sir. Okay, the second attachment is just some -- kind of detail of some of the statistical information that had been gathered. I believe this was for the last year, and it shows kind of various categories of -- of the percentage between the city and the county on -- on the patients, the average call time. I might add that that percent of loaded miles, we make a lot of runs in which we'll go and the patient will decline services for whatever reason, and so we then come back. Now, we do have a charge for that; I believe it's $50. Again, it's in one of those schedules. And -- but -- but that's not included in our stat here of a loaded mile. In other words, that's -- that statistic is only when we bring a patient back in with us. COMMISSIONER WILLIAMS: Do you have any feel for how many, or the percentage of your trips that would result in no loading? MS. DAMS: No, sir, I don't. And I'm not sure -- I'm not sure if it's in one of these -- this backup information or not. I don't -- I don't know. I got kind of amused the other day; I was talking with Todd Bock about this, and I showed him -- or he asked, and I said, "Well, we charge $50 when we go out to make a run." He said, "My gosh, I charge more than that for a mechanic on an RV when they don't -- when I send them out and they don't do any ~-i; us jwr. 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 work." So, that's an area we may want to look at, you know. I don't know. It's -- maybe that's -- maybe that's not enough. COMMISSIONER LETZ: How -- this is more kind of a general question as to how you keep track of your data, as to what questions we can -- or data we can ask for. Do y'all keep track of where the -- I mean, obviously, where the runs go, but how much in the -- can you give us a breakdown of where in the county these runs are? MR. DAMS: I don't know, Jonathan. COMMISSIONER LETZ: And the reason I'm thinking on that is that the -- and I hope y'all are aware that part of eastern Kerr County is about to probably go to Kendall County, which would be the longest run times that you probably have. MS. DAMS: Right. COMMISSIONER LETZ: And that we -- and that Precinct 4 has got rid of another section out near Kimble County, so the long runs are probably going to go down in the future, time-wise. I mean, parts of the county, just because we're trying to handle those areas, or part of them have been handled. And it appears that the eastern area of Kerr County is going to go to Kendall County for primary -- for primary call, though there will still be -- it's -- have you met with Eric about what our discussions were? ~-13 US jwk. 16 1 2 3 9 5 6 7 8 9 10 11 12 13 14 15 15 17 18 19 20 21 22 23 24 25 MS. DAMS: No. And I'm -- no, I haven't. I have not. COMMISSIONER LETZ: Well, the -- where we are on that, last meeting that we had with Kendall County was that if the Comfort ambulance is available -- well, all -- a certain number of Comfort area phones, from a dispatch standpoint, will be switched to Kendall County. They will then dispatch the Comfort/Kendall County ambulance if it's available. If it's not, they will manually call Kerr County dispatch, and the ambulance will come out of Kerrville. So, it's kind of a joint -- because Kendall County is not going to get in a situation where they have both of their ambulances -- one ambulance busy and the other one in Kerr County; they only have pretty much two on call so that's kind of the direction where it's going. So, it's going to have an impact on dispatch, minimal. It's not that many calls in this area, I don't think. COMMISSIONER WILLIAMS: Is one of those ambulances stationed in Comfort? COMMISSIONER LETZ: Yes, most of the time. So, anyway, that's kind of what we're trying to work out there, but it'll -- it's going to be a hybrid from what we did out in far west Kerr County. MR. WAMPLER: To answer your question, Jonathan, yeah, we -- the fire and EMS can tell you every I ~-13-05 jwk 17 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 15 17 18 19 20 21 22 23 24 25 run, the time on the run, the -- you know, the address and all, but I don't think that it shows that in terms of graphing it or charting it on the county map, or -- COMMISSIONER LETZ: 'Cause I think what would be interesting would be, you know, I guess the percent of the runs that are -- you know, how many of them are right around Kerrville, which I would think that a lot of the runs are because of the population makeup. Most of them are really no further than inside the city limits. I mean, they're -- you can get to Kerrville South or areas at Whiskey Canyon -- COMMISSIONER BALDWIN: Or you could just use the ETJ. There's some areas that are basically the same run time. But, obviously, if you get out into, you know, some of the areas around Hunt or Center Point, obviously, those are going to be longer run times. MS. DAMS: Right. COMMISSIONER LETZ: And I think distribution is important. COMMISSIONER WILLIAMS: Or you could take an average of run time of all city -- all city calls. COMMISSIONER LETZ: Right. COMMISSIONER WILLIAMS: All within the city or ETJ. What's the average run time of all of them? And anything that exceeds that is -- ~-13-US lwk 18 1 2 3 9 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 COMMISSIONER LETZ: Well, they have the average of the city -- I think they have those. It's just trying to get a feel for how many of them are long runs in the county versus how many of them are ETJ-type runs. MS. DAMS: The -- and David's right. I mean, we've got all that information. I guess it's just a matter of, you know, trying to make some -- COMMISSIONER LETZ: Try to figure out. MS. DAMS: And we could spend probably three or four man years just running stats on this thing. COMMISSIONER LETZ: Right. MS. DAMS: I think the significance of this is that, you know, you -- looking at this in a myriad of different ways, the City's position was, you know, it looks as if that it's a -- probably the most logical would be just to split it fifty-fifty as far as -- as the subsidy, so that's what's proposed with this dor_ument. And then Attachment 3, of course, is a proposed interlocal agreement, which the base year -- the initial year is coming up, October 1 through September 30. There's some termination provisions in there that -- that either side can mutually terminate at any time, and there's some 90-day written notices, and then some provision in there when a party has breached their obligations in the contract. Then it goes on to say that -- that the agreement can be renewed for a ~-13-OS jwY, 19 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 -. one-year period following the initial period. It sets out the level of services that will be provided by the City, and my understanding is that these just kind of mirror what we're doing now. I don't think there's any drastic change one way or the other in the level of service. Part of this is maintaining two ambulances, you know, that's available. There's some reporting requirements, and then the payment provision, Section 3, calls for the numbers that we just went over. And then, if it goes into a second year, there's a provision for an annual increase of whichever is greater, 5 percent or a formula that takes into account the C.P.I. of the medical industry as well as the transportation industry. And I think that's about it as far as the contract. As far as I was concerned, those were the salient kind of points in the contract. Buster, I didn't know whether y'all wanted to get into these questions and answers? Or, at this point, I guess I'll leave it up to you as to how we want to go. COMMISSIONER BALDWIN: Sure. COMMISSIONER LETZ: I didn't bring my question and answer pages. I read them a long time ago, and then they were kind of -- MR. WAMPLER: You can have those. COMMISSIONER BALDWIN: I think there is several of us at the table that do have -- do have questions. ~-1~ 45 jwk 20 1 L 3 9 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 COMMISSIONER NICHOLSON: Commissioner, could I talk a little bit about strategy before we get into the details of the -- COMMISSIONER BALDWIN: Sure. COMMISSIONER NICHOLSON: -- content? I see that some services that governments pay inure the benefit of a small percentage of the population, and sometimes those -- that population can be identified. And this might be one of those -- it might be one of those that fits the user-pay sort of strategy. And I see we're providing medical service, and that we do like doctor's offices do and like hospitals do, and their strategy -- and they deal also with things like bad debt and Medicare disallowables and HMO's and all the reasons why they might not get paid what their services cost. But their strategy appears to be one that charges an amount that takes into account that there'll be bad debt and HMO's, all that stuff. And while we may not like it, when I go to the doctor's office and pay the amount I pay, I'm paying for deadbeats and for HMO's and bad debt, but my doctor doesn't just break even; he makes a living by charging an amount to all the rest of us that will more than cover his costs. And I presume hospitals charge an amount that acknowledges these losses that -- COMMISSIONER WILLIAMS: They do. COMMISSIONER NICHOLSON: Where they at least ~-13-US jwk 21 1 2 3 4 5 6 7 8 9 10 11 12 13 19 15 16 17 18 19 20 21 22 23 24 25 break even, I think. I don't know that. But that leads me to think that we ought to have a strategy that -- that's a user-pay strategy; that we ought to adjust our fees in a way that eliminates the losses that we incur on providing EMS. MR. WAMPLER: Dave, I don't know if we've looked at that in great detail, but I can tell you that the reason that we are in the situation that we're in are two things. I think the majority of our runs are Medicare-reimbursable, Medicare-eligible runs, and so I don't know what the percentage would be, but let's say for the sake of argument that 80 percent -- this is entirely hypothetical -- 80 percent of our runs are Medicare-eligible, and 20 percent would be private-pay or some other insurance pay. If -- if that were the case, I think the burden, potentially -- the incremental cost increase that you'd have to put on the 20 percent to subsidize the 80 percent would be pretty high. Again, I don't know if we've looked at that, but the fact is, as I'm sure you know, on the Medicare side we're -- we're not allowed by law to bill that difference. In other words, we have to take that Medicare reimbursement, and we can't go back to the patient and try to collect the balance that's owed. COMMISSIONER WILLIAMS: MR. WAMPLER: Medicare Medicare or Medicaid? I mean, I don't know ~ 13 O5 jwk. 1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 22 what the percentage is, but it's more than 50 percent of our runs are Medicare-eligible runs. MS. DAMS: I think I have that, and I'm looking for it somewhere. COMMISSIONER WILLIAMS: I thought you could go back and bill on Medicare, but not on Medicaid. MR. WAMPLER: I know in the medical environment, you can't do that at all. COMMISSIONER WILLIAMS: You'd know. You're closer to it than I am. MS. DAMS: Well, let me -- DODGE TINLEY: I'm looking at some analysis collection rates, and it shows of -- of 100 percent of billings of '03-'09 fiscal year, billings are almost $2 million, to -- to include 100 percent. Disalloweds are slightly -- are about 25 and a half percent. That would include the private-pay as well as the Medicare disalloweds, would it not? MR. DAMS: I'm sorry, I wasn't listening. I'm drawing over here. I was trying -- I wanted to come up with -- try to illustrate -- JUDGE TINLEY: Here's where I'm coming from. This was in response to some questions that I had. COMMISSIONER WILLIAMS: Which page are you on? ~-13-OS lwk 23 1 2 3 4 5 E 7 8 9 10 l1 12 13 14 15 16 17 18 19 20 L 1 22 23 29 25 JUDGE TINLEY: The page is not numbered, but it -- MR. DAMS: Yeah, I'm sorry about that. JUDGE TINLEY: -- it's under Item 7. And, I don't_ know, about Page 5. Excuse me, Item 9, overall collection rate for EMS service. MS. DAMS: Mm-hmm. JUDGE TINLEY: It shows '03-'04, which is the most recent entire fiscal year that we've got, total billings of just under a million, nine-plus as 100 percent billings. Disalloweds are -- are a little over 25 percent of that, so that would include all the disalloweds, be they Medicare, Medicaid, private HMO's, whatever? MS. DAMS: No, that would just be Medicare/Medicaid. JUDGE TINLEY: Okay. MR. DAMS: The actual disalloweds. MR. WAMPLER: Yeah. When we refer to disalloweds, we're actually referring to government entities short-paying our bills, so that doesn't include bad debt or any other, you Y,now, insurance or -- JUDGE TINLEY: That doesn't include what -- is there a right of recourse against the balance for -- MR. WAMPLER: No. COMMISSIONER WILLIAMS: Item 6 delineates ~- 1 9- ~~ S j w k 1 2 3 4 5 5 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 29 25 24 that. It talks about -- MR. WAMPLER: Right. COMMISSIONER WILLIAMS: -- the Medicaid disallowed and the Medicare disallowed. MR. WAMPLER: Right. MS. DAMS: Let me try to illustrate. And these numbers aren't right, but it's just simple math, I guess. But, as an example, if -- if a run is $400, an average-cost run, the government says that Medicare/ Medicaid -- that the rate that they will pay is $300, and they have predetermined what the service out here in the Hill Country is for emergency medical services. So, $300; then they pay 80 percent of that. In this illustration, that would be $240. Now, what we can try to do is we can try to collect that $60, the difference between their 80 percent and -- and the 100 percent, and this is often done by supplemental insurance on Medicare, or just -- we'll actually bill the patient. But when we enter into an agreement with the government to receive the Medicare, we agree that we will not ever try to collect that amount -- that part. So, it's this $100 in this illustration that we call disallowables. COMMISSIONER NICHOLSON: So, the strategy I was talking about would, for example, require us to get out of the Medicare contract. And that's what some health ~ 1 3- U S ~ w 4: 25 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 providers do. My doctor won't accept Medicare. He bills me the full amount of services, and -- MS. DAMS: And his fees probably went down, I would imagine. But, yeah, you could raise that rate, David. But you can't -- you know, you don't have any control over their ceiling, so -- MR. WAMPLER: That's actually a moving target. That's changed over the years, and will probably continue to change. JUDGE TINLEY: Is not the rule, rather than 100 percent of Medicare allowables, 115 percent? I MS. DAMS: I don't know. JUDGE TINLEY: I'll give you a for instance. I've been under the Tricare program, which, of course, is very similar to the Medicare program. And the -- if I'm not mistaken, of course, they pay a certain percentage under Tricare Basic, and then they can -- the doctor or provider can collect up to 115 percent of what Medicare allows, or in this case Tricare, for that specific procedure, the 300 in your example. MS. DAMS: So, that would be up here somewhere. JUDGE TINLEY: Yeah, that would be $345, for example. So you could collect the difference between 240 and 345. 7-13-G5 ~wk 26 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 L ~ 23 24 25 MS. DAMS: I don't know. But -- JUDGE TINLEY: I -- that's what my understanding was here a couple of years ago. Now, as Mr. Wampler said, that's a moving target, and I'm sure the rules change. MR. DAMS: We'll check on that, because if that, in fact, is the case and we're not doing it, then we need to be, absolutely. COMMISSIONER NICHOLSON: What I'd like to create is a model -- economic model that says, "Here's what our fees would have to be to break even." It might be with Medicare or might be without Medicare, and transfer that -- that cost to the users. COMMISSIONER WILLIAMS: Don't we have a utilization statistic that shows Medicare versus private pay? Don't we have a statistic that shows that percentage of -- percentage of patient load that is either Medicare/Medir_aid covered as opposed to private-pay covered? COMMISSIONER LETZ: Page before that. MS. DAMS: I think we do. COMMISSIONER LETZ: The page before that. MS. DAMS: May be this source of payment. That's Item 6 under -- COMMISSIONER WILLIAMS: Item 6? MR. DAMS: -- Judge Tinley's letter, that -- ~-13-OS ;~w k. z~ 1 2 3 9 5 E 7 8 9 10 11 12 13 14 15 16 17 l8 19 20 Ll 22 23 24 25 COMMISSIONER WILLIAMS: Yeah. MS. DAMS: -- you need to add up -- you know, there's several Medicare. Here's -- COMMISSIONER WILLIAMS: Well, 21 percent. JUDGE TINLEY: That's the income -- well, no, that's -- that relates to the total -- some of it is not payment. Some of it -- MR. DAMS: No, it's not payment. It's just the source of the payment. MR. WAMPLER: The source of the payment. MR. DAMS: Yeah. And I -- MR. WAMPLER: So, if you add the Medicare check, Medicare disallowed, Medicaid, Medicaid disallowed, and then go down to Medicaid check, electronic funds transfer and add those up, that's -- you know, those are all the source of payments that we receive. MS. DAMS: Over 90 percent. COMMISSIONER WILLIAMS: We11, personal check, business check, private insurance check, private insurance disallowed -- MR. WAMPLER: Right. COMMISSIONER WILLIAMS side of that -- MR. WAMPLER: Exactly. COMMISSIONER WILLIAMS: -- becomes the other -- equation. Is that 7-13-OS ~wk 28 1 2 3 9 5 E 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 correct? MR. WAMPLER: Right. COMMISSIONER LETZ: Going back to Item 9, the chart -- MS. DAMS: On which? COMMISSIONER LETZ: On Judge Tinley's responses, the next page. MS. DAMS: Okay. COMMISSIONER LETZ: Okay. I understand the billings. Obviously, disalloweds, I understand. Allowed collectibles. So that's how much we can go after? MS. DAMS: Right. COMMISSIONER LETZ: Bad debt write-off, 16 percent, which is 315,000. That seems like a high number to me, that that much is written off. Is that not high? I mean -- MS. DAMS: I would say, industry-wide -- and I can't quote you a number, Jonathan, but I'd say that's probably pretty low, really. And if you take -- I made myself a note here. If you take what we do collect out of what is eligible to collect, we're collecting about 78 percent. And, again, I think, industry-wide, that's -- that's a good collection. Now, let me tell you kind of the process, as I understand it. We -- we'll send out a letter and follow up on -- with these people that we bill, and then ~-13-05 jw4: 29 1 2 3 9 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 after one or two letters, we actually turn that over to a collection agency and they try to work it for us. So, I'm not real sure what more can be done. David and I visited briefly yesterday about the fact there are a lot of companies that -- that -- in the medical industry that do the billing and collecting for doctors, hospitals, clinics and emergency medical providers, and I think that's something we may want to look at. You know, I don't -- probably not right now, because we just got some other priorities we need to do, but maybe this winter sometime, just to see if we can increase our collection rate at a lower cost. And, certainly, if that's the case, I think that would be something we could do. COMMISSIONER LETZ: Does the City have a collections department, before you turn it over to a collection agency? MS. DAMS: Yes. MR. WAMPLER: Yeah, we have a dedicated EMS clerk. Collection billing system, yeah. MS. DAMS: Yeah. JUDGE TINLEY: The one out of the Coronado office there? MR. WAMPLER: Yes. COMMISSIONER WILLIAMS: Couple comments here, gentlemen. I really want us to work out an equitable 7-13 ns jw4: 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 situation. I want the County to continue to contract with the City for these services, but 7'm having a difficult time, honestly, getting past the initial stats, the utilization statistics which show that within the city limits, 76 percent, by your analysis, are city runs, and outside, which would be county runs, is 20 percent -- they're fractions in each case, but just for the sake of discussion -- leaving about 4 percent for others, which would be Ingram and whatever, or outside the county. Outside of the county's going to disappear; that's .8 decimal percent. So, I'm having a hard time wrestling with the utilization statistic. I believe we should pay our fair share, and if we -- if we agree that there needs to be a county subsidy for disallowables, those disallowables need to be our fair share of what takes place in the county, as opposed to a piece of what takes place in the city. So, you got to help me get over that. MR. WAMPLER: Bill, go back. And you said 76 percent? Tell me -- COMMISSIONER WILLIAMS: Well, I'm looking at this -- the one that came from Brian Brooks. It's called EMS -- it came from Brian June 10th; was sent to Commissioner Baldwin. It's page 7A. MR. WAMPLER: All right. COMMISSIONER WILLIAMS: I can also look at 7-13-0 S jHr k. 1 L 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 29 25 31 yours. MR. WAMPLER: I gave mine to Jonathan. COMMISSIONER WILLIAMS: Yours says 26, but there's still a pretty huge disparity there. MR. WAMPLER: So you're looking at run count. To answer your question, in one way -- as Don said, there are a lot of ways to look at the data. There's number of patients. There's loaded miles. COMMISSIONER WILLIAMS: Mm-hmm. MR. WAMPLER: There's total mileage, to name three. And what we're looking at is actually utilization of the resource. And if you -- if you call the resource the actual personnel and the vehicles and the time that they're on a call, the mileage -- or whether it's the mileage or the time, that's what we're trying to take a look at. We're not looking at -- I mean, you're right; if you look at the number of patients, the actual number of bodies taken to the hospital or the people that are tended to, there is a disparity. But if you look at the -- the mileage that we're putting on both the personnel and the vehicles to handle calls in the county -- and, admittedly, Jonathan makes a decent point, that whether they're in the ETJ or whether they're in far west Kerr County or far east Kerr County, we haven't sliced that. We've said if they're in the county, which we have done that analysis. We're looking at the 7-13-OS jw4: 32 1 2 3 4 5 6 7 8 9 10 11 12 13 19 15 16 17 18 19 20 21 22 23 24 25 total number of miles, which comes out to about 50 percent. COMMISSIONER WILLIAMS: Let's take a look at personnel -- and picking up on your point, personnel and mileage. Personnel, for all practical purposes, is a fixed cost. It's part of your fire department and so forth; that's part of it. And if you want to take an extension even beyond that, the City -- the County pays a piece of that by reason of our fire contract, so we got -- we got a bite of the personnel cost already. MS. DAMS: No, Bill, that's not right. MR. WAMPLER: Actually, that's not true. MS. DAMS: It's two separate departments, and we account for them differently. COMMISSIONER WILLIAMS: Personnel are interchangeable. MR. DAMS: Our people are cross-trained. Now, some of which have -- you know, if you and I are primarily assigned to the ambulance operation, our salary is in the ambulance department, you know, so we do keep accounting separate for these people. COMMISSIONER WILLIAMS: Okay. Even given that, are there any statistics that would show that the runs into the county, which, again, is a smaller percentage of the whole -- MR. WAMPLER: In terms of numbers of runs. ~-13-OS ~wk 33 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 COMMISSIONER WILLIAMS: Number of runs. Are there any statistics that -- that would show or indicate that overtime was involved for these personnel because of that? MR. WAMPLER: The way we're looking at it, Bill, is that we have to maintain a staffing and equipment level to serve all of the constituency that we're serving, including the county right now. That is a fixed cost. COMMISSIONER WILLIAMS: Right. MR. WAMPLER: If we weren't serving the county -- and I can't tell you what it would be, but those fixed costs could be eliminated to some extent, or could be reduced to some extent if -- if our population and area size was reduced. So, there is a fixed cost associated with serving that wider area that we maintain all the time. And -- and so, rather than saying to the County, "We have a $1.7 million budget, including that fixed cost, to provide the service to all of the county and the city, and, you know, 50 percent of that resource is used outside of the strict city limits of the city of Kerrville, so therefore you should pay for half of that budget," we're not saying that. We're saying that we have done this as an enterprise fund for many years, and due to circumstances beyond our control, we're running a deficit. COMMISSIONER WILLIAMS: Mm-hmm. ~-13-05 jw}: 39 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 MR. WAMPLER: And we're asking for -- based on the time and the mileage spent serving needs outside of the city limits, we're asking for 50 percent of that deficit to be covered. COMMISSIONER LETZ: But let me -- COMMISSIONER WILLIAMS: Deficit? Let me ask one question. COMMISSIONER LETZ: Okay. COMMISSIONER WILLIAMS: But the deficit -- let's deal with the deficit. The deficit is predicated on the whole. MR. WAMPLER: Mm-hmm. COMMISSIONER WILLIAMS: The number of patients and the whole load. MR. WAMPLER: Mm-hmm. COMMISSIONER WILLIAMS: Right? And if the County's stat is, say, 20 percent of the whole or somewhere in that vicinity, you're saying that we should make up the other 30 percent to get us to parity on the deficit, and I don't -- I don't follow that. COMMISSIONER LETZ: I guess what -- I'm following up on Bill's -- it seems like the City is basing this on miles. Well, I think the -- you know, I think it's closer to being accurate to base on it calls. And the reason is, dispatch is a great example. We're adding in ~ 1~-05 ~wk 35 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 15 17 18 19 20 21 22 23 24 25 $75,000 in dispatch costs to the county. There's no more dispatch for a call that takes -- that goes to anywhere, I mean, outside, and that's a fixed cost. I mean, that's more per call, so, clearly, I can see that there should maybe be an adjustment based on miles or mileage on the vehicles. COMMISSIONER WILLIAMS: Mm-hmm. COMMISSIONER LETZ: But I think the -- the fairer way to do it is look at the number of calls, which is -- on this chart, is 69 percent in the city and 26 percent in the county. The other numbers that we had are a little bit -- like, 72 percent or whatever it was in the city and 26 percent in the county. And then I think it's fair to look at that and then say, okay, granted, there's the usage, and then a higher -- you know, there's a surcharge to the County because the calls in the county are obviously further. JUDGE TINLEY: That's the reason -- COMMISSIONER WILLIAMS: On mileage as well as vehicle maintenance. COMMISSIONER LETZ: Yeah, on the whole equipment side. I mean, on the equipment side, the County pays a surcharge. JUDGE TINLEY: Well, but that was one of the reasons I asked about portions of revenues derived from various segments of the charges imposed. There's a base ~-13-GS jwk 36 1 °' 2 3 4 5 6 7 8 9 10 11 12 -- 13 14 15 16 17 18 19 20 21 22 23 "°'° 2 4 rate which applies whether they're driving across the street or driving 100 miles. COMMISSIONER WILLIAMS: Mm-hmm. JUDGE TINLEY: Now, once they pass a given mileage portion -- and I don't know exactly what that is, but once they reach a certain plateau, they start to accrue additional mileage charges. And I asked the portion of total revenues derived from basic mileage or basic charges, patient pickup and additional mileage charges. The breakdown -- I'm not sure how they've arrived at the percentages. That's in Number 3. The base rate was a million, 567. Then we just have mileage, whether or not -- I don't know whether that's basic mileage charge or additional mileage charge, or just what's shown on mileage in the billing that comes out. I don't have that. That's 540, which would be, what, approximately a third, I guess, of -- of that. That was the basis for my question, is what -- what's generated, whether they're driving across -- across the street or across the county, and then what additional charges come into play and what percentage of -- of charges are generated from that? And -- and I think that's a telling picture, and it somewhat relates to what we've -- what we've got here on the utilization analysis. I didn't see the figures that Bill had about 76. That's 25 I different from the system analysis -- utilization analysis ~ i3-os SwF: 37 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 29 25 that was provided initially that shows 69 percent and 26. And of course those don't add up to be 100, but Ingram's out there, so that will probably account for the difference. COMMISSIONER LETZ: It just looks to me -- it's hard to justify going to a fifty-fifty split when basically 25 percent of the calls are in the county. I mean, I just -- I don't see how you can get there, because there's not -- MR. WAMPLER: Well, the average length of the call in the county is greater than the average length of the call in the city, but the utilization of the truck is longer on average. COMMISSIONER LETZ: But the dispatch is a fixed cost. The employee time, salaries, all that's a fixed cost. The basic equipment is a fixed cost. The only thing that's costing more is the excess -- or the more usage of the vehicles in the county. MR. WAMPLER: And that fixed cost associated with having the staffing necessary to cover the entire county is increased due to the fact that we're covering the county. Our fixed costs if we were only covering the city of Kerrville would be less. COMMISSIONER WILLIAMS: Could you reduce your staff 20 percent if you weren't -- MR. WAMPLER: I don't know what the number 7-13-GS jw4: 38 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 is, but I assume we could. COMMISSIONER LETZ: They're saying reduce it 50 percent. You should be able to reduce -- MR. WAMPLER: I don't know what the number is. COMMISSIONER LETZ: I'm saying under that argument, though, you could reduce that 50 percent if the county wasn't here, and I don't see that you can reduce your staff 50 percent in your EMS, from what I see. 'Cause, I mean, that means you'd have to go to one ambulance, and I don't think that Kerrville could do that. My other question is -- and, you know, I think you understand where we're coming from on this. And the other question I have, though, is all of this looks like it is -- someone calls 9-1-1, there's -- and you go out and send an ambulance. What about the usage of -- is that in here? The usage of transport from Sid Peterson to -- MR. WAMPLER: San Antonio? No, it's a separate -- COMMISSIONER LETZ: Well, 'cause I think that also needs to be put in the mix, because as I understand it, that is the -- the gravy, ~{ *h°r° ~° _^° ^r=°° ~^ °^^`, is those transports, 'cause you know you have insurance and you know you're going to get paid. And those need to be figured in here, because the fixed costs of the department and the ~-13-OS 'iwk 39 1 2 3 9 5 6 7 8 9 10 11 12 13 19 15 16 17 18 19 20 21 Z L 23 24 25 machinery and the wear and tear and all that is used. MS. DAMS: It is, Jonathan. And I -- MR. WAMPLER: Maybe I misspoke. MR. DAMS: I don't mean to correct the councilman, but yes, those numbers are in the budget, the revenue that's generated. COMMISSIONER LETZ: I don't mean in the revenue; I mean in these figures here. MS. DAMS: All right. Now, the transfers, as I understand this report, are not included. MR. WAMPLER: Transfers are not here, but they are included in the dollars. MS. DAMS: But, yes, that's correct. COMMISSIONER LETZ: But what I'm saying is, you need to look at that time and that usage and that loaded miles, because that is a -- the County, I mean -- MR. WAMPLER: We have a dedicated transfers box; it's an older ambulance, so the transfer box is not -- unless it's an emergency where we have all of our ambulances out. COMMISSIONER LETZ: Right. MR. WAMPLER: That -- that transfer ambulance is a dedicated transfer ambulance. COMMISSIONER LETZ: Okay. MR. WAMPLER: So, do you see what I'm saying? 7-13-OS jwk, 40 1 2 3 9 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 And we made adjustments for that two years ago. So, you know, not to say that if we had all of our ambulances out and the transfer box is available, we wouldn't send on it a county or city run. We would. But under normal operations, that's a dedicated transfer ambulance. COMMISSIONER LETZ: But what about the staffing, I guess? I mean, are any expenditures associated with that ambulance coming in here? I mean, the revenue needs to be included if the expenditures are included anywhere. MS. DAVIS: And they both are. COMMISSIONER LETZ: Okay. MR. WAMPLER: I mean, yeah. We don't have a dedicated transfer staff. We do have a dedicated transfer ambulance, though. COMMISSIONER LETZ: Okay. MS. DAVIS: But the numbers are not included in this analysis, because this is just based on the emergency -- COMMISSIONER LETZ: Right. But, I mean, some -- and I -- it's legitimate to not include the miles if it is a dedicated ambulance. MS. DAVIS: Right. COMMISSIONER LETZ: That's fair. MR. WAMPLER: I mean, just to be clear -- and 7-13-OS ~wk 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 l~ 18 19 20 21 22 23 24 25 41 I know we're beating a dead horse at this point -- these numbers are based strictly on calls for service associated with 9-1-1 calls saying, "I need an ambulance." It doesn't have -- the transfers are not built into these numbers at all. COMMISSIONER LETZ: These -- I'm sure it's in the front. What year -- this is '03-'04? MS. DAM S: I think so. That's my understanding, Jonathan, yeah. COMMISSIONER WILLIAMS: Let's see. MR. WAMPLER: I guess, speaking of that, we have -- this is a relatively new item. This is more up to date, these kind of charts, disallowables and how it's grown, you know, since '96. And it's actually dropped off a little bit. That's where I referred back to the fact that it's a moving target. I didn't come back and look, obviously, on an annual basis to see where we're at, but, I mean, this is up to -- you know -- COMMISSIONER LETZ: Does the city -- or is the City in the process of, for this budget year, really looking at your pay structure? I know other counties around here are doing that, 'cause everyone, I think, has the same -- MR. WAMPLER: We haven't gotten into that from a budget standpoint, but that's something that we've ~ i3 os Iwo 1 2 3 4 5 6 7 8 9 10 11 1L 13 14 15 16 17 18 19 20 21 22 23 24 25 42 identified that we need to continue to look at. And I'll tell you that previous to five or six years ago, our pay structure, both in the fire department and EMS and police department, were -- we were essentially training ground. COMMISSIONER LETZ: I don't mean salaries; I'm thinking more service. You know, I think it was a -- someone said it was $50 a run to send an ambulance out. I'm kind of like -- I think it was Ron that made the comment that, "I wouldn't go anywhere for 50 bucks." MR. WAMPLER: I think that's something we need to take a look at, absolutely. COMMISSIONER LETZ: And I think -- I don't know how much of an impact that has on the revenue side, but I think that can easily be certainly doubled. COMMISSIONER WILLIAMS: This is kind of a view of what's happening -- MR. WAMPLER: Yes, sir. COMMISSIONER WILLIAMS: -- today? MR. WAMPLER: That's just a graphical illustzation of what disallowables have done and why, fairly suddenly, you can look at the -- you know, at 2001-2002 when we removed EMS from an enterprise fund where it was self-sufficient, you know, we can see a pretty significant spike in what the government was willing to pay versus what we needed to recoup or charge for our services. And, as I ~-13-0`_~ ~wk 43 1 Z 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 said, you can see at the top, we can't -- we don't know why, but it's actually started to drop off a little bit. Now, presumably, the government's reimbursing a little more than they had in the past. COMMISSIONER LETZ: It seems to me, since this is a workshop, we're kind of at a -- a stopping point in a way. I mean -- I mean, I think that the -- what I'm hearing is that -- our side, is that we think that the way the City come up with the breakup of fifty-fifty based on more on mileage isn't fair, because there's lots of costs in there that have nothing to do with us, such as fixed costs of salaries and the -- and the equipment and dispatch and all that clearly are not a fifty-fifty split, because it's a -- those are usage numbers. But that there is a feeling that there is a surcharge which would be appropriate from the -- for the mileage and longer distances in the county. You know, and I don't think that you all can answer that, because, obviously, you're talking about one councilman and a City Manager. You know, I think the -- my feeling is to ask y'all to go back and look at that. Whoever -- I don't know if this is a City Manager decision or a Council decision; I don't know where that came from, but I just -- I don't -- it doesn't seem fair to me. It seems that the County's being asked to pay more than its fair share. Quite a bit more. ~-i3-os iwr. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 44 COMMISSIONER NICHOLSON: Jon, I -- from what I've learned from this and what I'm hearing everybody say, I agree with you, that I don't know what our fair share is, but it looks like it's something less than 50 percent. COMMISSIONER LETZ: And a lot more than what -- where we are right now. I mean, clearly, we're not paying our fair share now. MR. DAMS: Well -- COMMISSIONER WILLIAMS: I agree, we're not. MR. DAMS: Gentlemen, I think the three important things that we have here is the -- the percentage of the loaded miles; that's the -- when we're carrying patients, and then, to me, the average call time, and then the -- the percentage of those last three statistics, all of which are right around that 50 percentile, or 50 percent split. But the calls -- we're not going to staff up based on the number of calls, because it just -- I mean, that's almost an immaterial statistic. What's important from a staffing standpoint is the time that we're spending providing the service and the cost of that in terms of, you know, manpower and equipment, which gets back to time and miles. COMMISSIONER LETZ: But how can you justify us paying additional -- I mean, 50 percent of -- or two additional for dispatch? I don't see how that fits into ~-i3-os ~wti 1 2 3 4 5 6 7 8 9 10 11 1L 13 14 15 16 17 18 19 20 21 22 23 24 25 45 this. I mean, how does dispatch costs increase because you're out on a run longer? MR. DAMS: Well, a certain -- there is a certain cost to provide this service that includes the dispatching, and that's why that number -- the 74,000 or whatever that number is, in order to reflect that cost to this service, you have to include it. And you're exactly right; you know, the dispatcher receiving the call and dispatching the -- the unit, whether it's in town or out of town or in Gillespie County, that -- you know, that doesn't affect what the amount of time that she or he spends on that deal. But all -- all we have determined here is that, based upon, again, time, that the $74,000 representing, I think, approximately two dispatchers, if this were a stand-alone operation, we'd have to have two dispatchers to cover the -- the communication needs of that -- of the ambulance. COMMISSIONER WILLTAMS: But, Don, it's not -- it's an integrated operation, and I think Jon's point is valid. For the dispatcher, a call coming in for police services, fire services, EMS services or anything else is just a call. It's a call. MS. DAMS: Sure. COMMISSIONER WILLIAMS: Doesn't take a man or woman any more time to dispatch an ambulance as it does to dispatch a police car. ~-13-OS ~wY. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 22 23 24 25 46 MS. DAM S: That's exactly right. But if we did not have this ambulance service, what I'm saying is, then the six dispatchers or however many we have in the P.D. could be reduced by the equivalent of two persons. COMMISSIONER LETZ: No. JUDGE TINLEY: Let me get to the broader question. I think we would all agree that -- that the utopian answer would be that the user or the utilizer pay for the service. That's -- that's where we'd all like to get, MS. DAMS: Sure. JUDGE TINLEY: From a user standpoint, we've got two different figures. One is slightly under 70 percent; one's slightly over. That would seem to be a pertinent benchmark, because, based upon the revenue generated, and presumably the disallowables and the losses incurred, probably running the same proportion, we don't have anything to indicate otherwise. Now, granted, when you go on these longer runs out in the county, there are additional mileage charges imposed, and maybe some adjustment should be made in connection with that portion of the service utilization to provide that. Because of these longer runs, maybe a -- a larger percentage of that should be paid by the County. But when it comes to actual utilization, ~ 1 O S j w k 47 1 ~... ~ 3 4 5 6 7 8 9 10 11 12 -~- 13 14 15 16 17 18 19 20 21 22 23 °` 2 4 we're looking at approximately 70 percent -- maybe slightly more, based upon the more current call figures -- that are actually for city residents, and that's the utilizations that's user-pay that we're trying to look to. So, I think we've got to use both figures rather than just try and throw them all in one big hat and -- and say, "Well, we can't really figure this out, so we'll just slice it down the middle," or slice it some way or the other. I think we've got to figure what user -- what the user aspects are in the city and the county. And the base -- the base charges are apparently - - the vast majority are generated by -- by in-county -- I mean in-city service. And I suspect that the additional mileage charges that are imposed are out in the county, and we need to take a look at that. COMMISSIONER WILLIAMS: I think that same -- own system utilization, are -- are 26 percent of those attributed to calls out in the county, then certainly the County has responsibility for that piece. MR. WAMPLER: Well, first of all, I mean, I don't want to have it mischaracterized that somehow we threw a dart at this and came up with 50 percent. I'm not saying that it's not valid to look at number of runs, but 25 ~ effectively, as Don said, the number of runs are irrelevant. 7-13-n5 ju,x 48 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 I mean, if they're all half-mile runs spread across the county and the city, the fact is, we're looking at the use of the resource, which the is the equipment and the manpower, and it's the time in the vehicle, the time on the road, and the mileage. And that's not an arbitrary number; it's about fifty-fifty, and so that's why we came up with that. JUDGE TINLEY: It may well be that you need to increase that additional mileage charge. MR. WAMPLER: So -- DODGE TINLEY: If you've got an inordinate amount of labor costs allocable to additional mileage charges, maybe you need to increase that. MS. DAMS: Well, I Chink -- JUDGE TINLEY: That may be something you need to look at. MR. DAMS: The fallacy, in my mind, of that sort of breakdown, Judge, is that you've got costs associated with providing that service; that's what I'm going to call a standby cost. In other words, whether it's a fixed cost, whatever, but if we don't receive a call, you've still got a certain amount of those costs. And you can't -- you know, that -- by trying to put on it a mileage basis does not account for the costs that you have if you're in the station. You're just -- ~-1j-OS jwk 49 1 2 3 4 5 6 7 8 9 10 11 12 ---- 13 14 15 16 17 18 19 20 21 22 23 "`°' 2 4 25 COMMISSIONER WILLIAMS: We have the same type of formula for fire, and -- and we certainly pay our -- what we believe to be our fair share in terms of fire responses. You have fixed costs, both for manpower and equipment, and they're there and they're standing by. Then they may get one call in the county today, they may get five tomorrow and none the next day, but the costs are there, the equipment's there, and we pay our piece of that. I don't know why that -- I shouldn't say I don't know why, I'm questioning whether or not the same rationale or formula has been applied in this case. MR. WAMPLER: That may not always be the case. I'm not saying we've looked at that, but I'm saying that the status-quo that -- the situation we're currently in has been in place for many years, longer than anybody at this table's been in their current position, and circumstances beyond our control have changed, and we're trying to find an equitable way to solve that issue. Your example may be entirely correct, but I think it's not safe to say that that's always going to be that way. We do have those fixed costs for the staffing and equipment. We have dedicated ambulances that are, you know, serving the population that we have to pay for. And instead of asking the County to pay 10 percent, 20 percent, whatever it is of the entire budget, we're trying to show that our actual 7-13-OS ~wk- 1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 50 time, fixed costs, r_ontingency fund, what-have-you, is built into having that service available to all the citizens of the county, and we're upside down $375,000. We need to bridge that gap. That's the bottom line. And we can show that time in the ambulance and mileage is about fifty-fifty. COMMISSIONER LETZ: I understand that, but I just -- I can't get over -- I guess, let me go back to another question. Y'all -- as I understand it, there's two ambulances pretty much on call all the time in Kerrville, so what you're telling me is that if the County doesn't pay 50 percent, you're going to one ambulance? MR. WAMPLER: No. What I'm saying is that if -- if we did -- let's put it another way. If we didn't have to run into the county 50 -- 50 percent of our mileage, the wear and tear on our vehicles would not be as great as it is, okay? COMMISSIONER LETZ: And I agree. MR. WAMPLER: And the replacement costs and the replacement cycle of those vehicles would not be as great. COMMISSIONER LETZ: I agree. MR. WAMPLER: So the overall cost over time would be diminished by some factor. COMMISSIONER LETZ: Well, see, but -- no. I agree with the vehicle part of it; there's an excessive cost ~ 13-OS jwk 51 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 29 25 or more of a surcharge to go to the County. But all of your manpower and everything else, your infrastructure, administration, all that is not going to change whether the County's around or not. I mean, you're going to keep -- I cannot imagine that Kerrville's going to go to one ambulance if the County -- if the County didn't exist. Because the population -- 'cause there's no -- I mean, I don't think they physically could handle over 70 percent of the calls that they're currently getting with one ambulance, so I think that there's a -- MR. DAMS: Well, I disagree with you, Jonathan. I think there will be -- if we cannot agree on a contract here and the City stops providing service in the county, I think there will be adjustments in the operating department. COMMISSIONER LETZ: I think adjustments, but I don't think it will be a 50 percent reduction. MS. DAMS: I don't know what that number is. MR. WAMPLER: We're not askinq for 50 percent participation in the whole budget, so we're not comparing apples to apples. There would be a reduction that would be, I think, easily commensurate with the amount that we're asking for the County to help us with on the down -- on the down side. I mean, that could be two -- two and a half people. ~ 1?-n5 jwk. 1 2 3 4 5 5 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 29 25 52 COMMISSIONER WILLIAMS: Might be. But just go back -- I'm hung up on the 26 percent stat and the disallowables. A disallowable is a disallowable, whether it's a city call or a county call, and the only percentage -- only stat that resonates with me is -- is the 26 -- 26 percent of the whole. MR. WAMPLER: Mm-hmm. COMMISSIONER WILLIAMS: Of disallowables. Anything above that, to me, is an inflated -- is disparity, let's put it that way. If the -- you know, it seems to me it breaks -- the pie breaks up that way. A disallowable is a disallowable no matter how far a way it is or how close it is, how long it took or how long it didn't take. COMMISSIONER NICHOLSON: We wouldn't have to have this discussion if we agreed that it ought to be a strategy of user-pay. JUDGE TINLEY: User-pay. MR. WAMPLER: Right. COMMISSIONER LETZ: The -- and another note, though, I think that the -- this is made based on 2003-2004. Certainly, even if we were -- if I was to agree to go with these numbers, there'd be adjustments for eastern Kerr County and western Kerr County going to different services, which are the longest runs and are going to increase your run times, percentage-wise, probably pretty substantially. ~-is os 1wx 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 I9 20 21 22 23 24 25 53 There's not that many calls that go into those areas, but they are, by far, the longest, just 'cause it's -- you're talking about, minimum, hour and a half, if they don't spend any time there. And -- I mean, and in our -- they don't -- everyone over here may not know yet, but in the budget, I'm going to ask that we subsidize Kendall County, give them some money to do this. I mean, I'm not -- we can't -- there's no way we can just ask them to send an ambulance up into Kerr County for nothing. So I think -- I mean, clearly, we have to -- that has to be looked at, as well as look into the fact that there's -- the extreme long-distance runs are being taken out. MR. WAMPLER: Well, I think, again, one of the issues is the fact that we haven't looked at this in this detail in a long time, and this is a one-year contract. And there are a lot of issues here, like the impact of Kendall County serving and like the impact of Kimble County serving the west part of the county that we can't quantify yet. And I think, to the extent that we can look at those on an annual basis and come to some understanding about how we're going to split the burden will be useful in the next several years. But I don't -- we can't answer those question right now. COMMISSIONER LETZ: Well, I guess -- you know, again, I said probably 15 minutes ago I think we're ~-13-US ~w}; 54 1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 done today. 'Cause it seems that we have a view and you have a view, and -- MR. WAMPLER: What I was going to say, Jonathan, we've looked at this -- and I'm not saying that there's not some room here somewhere, but rather than us going back and coming back with another proposal, we'd like to -- I mean, I'm hearing from Bill that there's some disparity with regard to disallowables on county patients versus city patients, and I'm hearing from the Judge there's -- there ought to be some whittle room on mileage and surcharge for mileage beyond a certain amount. I'm hearing from you a slightly different issue. So, I mean, I -- I want to hear from you guys, rather than us coming back with another proposal. Because, I mean, there's not any agreement amongst yourselves. COMMISSIONER LETZ: I think there's agreement that the -- MR. WAMPLER: No, I understand, but there's not any agreement in terms -- from what I'm hearing today, in terms of methodology. COMMISSIONER LETZ: You want us to give a counterproposal, so to speak? MR. WAMPLER: Sure. This is our proposal. I don't think we need to come back with another one. COMMISSIONER BALDWIN: I agree. ~ i3-os ~wx 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 55 JUDGE TINLEY: Certainly. COMMISSIONER LETZ: I agree. COMMISSIONER WILLIAMS: We can do that. JUDGE TINLEY: That's a proper request. COMMISSIONER BALDWIN: And I hope that -- one of my ideas -- one of my thoughts is -- is going back to the way my granddaddy or our granddaddies would do this thing, and consider -- just consider using the old barter system. Can we trade our animal -- part of our animal program for part of the ambulance program? Can we do your collection? We have a Collections Department here that can be very aggressive. Very aggressive. And, you know, can we look at some of those kinds of things and do a little trade-off? I think it's worth thinking about, at least. COMMISSIONER LETZ: I agree. And I guess the final point -- and I didn't bring it up, because I'm not sure -- I hate asking questions when I don't have any vague idea what the answer is. Indigent calls. What -- do you have any idea what percent of these goes to indigents? MS. DAMS: No, sir. COMMISSIONER LETZ: And the reason I bring it up is 'cause the County pays 100 percent of that. I mean, we're paying -- and I don't want to -- I mean, I don't think it's a fair thing for -- when we have a homeless person who goes in an ambulance, okay, we're going to pay the ambulance 7-13-OS ~wk 56 1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 cost to get him to the ambulance, because it comes out of our indigent funds. You know, the hospital, we pay over there -- or provider, and then we have to pay it again. MR. WAMPLER: We can't qualify -- COMMISSIONER LETZ: I don't know how -- if you -- I don't know how you get into that. But, unless my mind isn't working right, on any indigent call anywhere in the county, we're already paying for that. And that's -- it's not y'all's fault; it's state law. The law says that we -- County's responsible for it, so we pay it. COMMISSIONER WILLIAMS: Up to 80 percent. COMMISSIONER LETZ: That's about $800,000 a year for us. Not -- I mean, total indigent. MR. WAMPLER: I don't know for sure, but I would think that indigents would be Medicaid-eligible, and if they're beyond a certain age, they'd be Medicare-eligible for reimbursement on EMS service. COMMISSIONER LETZ: I don't know. MR. WAMPLER: So, you know, of course, we can't qualify that before we make the run, and then if they don't pay us -- MR. DAMS: I'm sitting here thinking; we'll ask for a financial statement while he's lying there. (Laughter.) MR. WAMPLER: We don't split that out. ~-13-US jw4: 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 COMMISSIONER WILLIAMS: Guy living under the bridge, "Give me your financial statement." COMMISSIONER NICHOLSON: I was thinking out there on 1340, while I'm bleeding, I'm going to call and say, "How much do you charge to send an ambulance?" No. COMMISSIONER BALDWIN: Yeah. (Discussion off the record.) COMMISSIONER BALDWIN: Thank you guys very much. MR. DAMS: You bet. COMMISSIONER WILLIAMS: Good discussion. COMMISSIONER BALDWIN: I think we had a good discussion, and may not agree on everything, but at least we had a good discussion. We will -- we will come to some agreement before it's over with, though. COMMISSIONER NICHOLSON: Don, do you know if any governments that provide EMS do not agree to accept Medicare payments? MS. DAMS: I do not. Now, there may be, Dave, but I'm not familiar -- none of the cities in which I've worked had that policy. COMMISSIONER NICHOLSON: Do you think it's allowable? Can it happen? MS. DAMS: Oh, yeah, I'm sure. COMMISSIONER LETZ: How would you do that, ~-13 O5 ~wk 58 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 though? How would you -- when the 9-1-1 call comes in, dispatcher says, "Do you have -- are you on Medicare?" I mean, we just -- you don't allow, I mean -- COMMISSIONER NICHOLSON: You don't make a deal with Medicare to do it, so -- MR. WAMPLER: You just don't tell them, but you just -- you send them a bill, and then you get into a collections issue. I'm not saying it's good or bad, but then you're going to the patients, and if do you that, then you're not allowed to bill the government for the service. COMMISSIONER LETZ: What is your-all's -- what's a per-run cost? Do y'all have that? MR. DAMS: I haven't figured it. MR. WAMPLER: Raymond knows it. COMMISSIONER NICHOLSON: I took a ride in '99 in the same ambulance; it was about $800. And my private insurance company paid most of it, and I got a bill from EMS for the rest of it. MR. WAMPLER: My son had a transfer to San Antonio in '97 -- '98. It was $650. COMMISSIONER NICHOLSON: Probably 50 percent more now. MS. DAMS: It varies with the treatment we have to give, too. We have a base rate and 6,000 different add-ons. ~-13-OS ~wY. 59 1 2 3 9 5 6 7 8 9 10 11 12 13 19 15 16 17 18 19 20 21 2^ L 23 24 25 DODGE TINLEY: Thank you, gentlemen. That'll conclude the meeting. (Joint workshop adjourned at 10:13 a.m.) STATE OF TEXAS COUNTY OF KERR The above and foregoing is a true and complete transcription of my stenotype notes taken in my capacity as County Clerk of the Commissioners Court of Kerr County, Texas, at the time and place heretofore set forth. DATED at Kerrville, Texas, this 21st day of July, 2005. JANNETT PIEPER, Kerr County Clerk BY: __ ____ _Q__~ ~~~j ________ _ Kath~ Ban' De(d''County Clerk Certified Shorthand Reporter 7-13-OS jw4: