1 2 3 4 5 6 KERR COUNTY COMMISSIONERS COURT 7 and 8 KERRVILLE CITY COUNCIL 9 EMS Workshop 10 Wednesday, July 13, 2005 11 9:00 a.m. 12 Commissioners' Courtroom 13 Kerr County Courthouse 14 Kerrville, Texas 15 16 17 18 Kerr County Commissioners Court: 19 PAT TINLEY, Kerr County Judge 20 H. A. "BUSTER" BALDWIN, Commissioner Pct. 1 WILLIAM "BILL" WILLIAMS, Commissioner Pct. 2 21 JONATHAN LETZ, Commissioner Pct. 3 DAVE NICHOLSON, Commissioner Pct. 4 22 Kerrville City Council: 23 DAVID WAMPLER, Councilperson, Place 3 24 DON DAVIS, Interim City Manager 25 2 1 On Wednesday, July 13, 2005, at 9:00 a.m., a joint 2 workshop meeting of the Kerr County Commissioners Court was 3 held in the Commissioners' Courtroom, Kerr County Courthouse, 4 Kerrville, Texas, and the following proceedings were had in 5 open court: 6 P R O C E E D I N G S 7 COMMISSIONER BALDWIN: Good morning. Thank 8 you guys for coming over. This is our EMS workshop, and 9 appreciate the acting City Manager coming, and Mr. Wampler, 10 appreciate you coming back. And we have met previously, I 11 believe sometime in May. Let the record reflect the County 12 Judge is getting here a little bit late. 13 MS. DAVIS: Good morning. 14 JUDGE TINLEY: My apologies, gentlemen. 15 COMMISSIONER BALDWIN: Apologies accepted. 16 But we -- the City Manager and Mr. Wampler and I went over 17 this document that I have provided for y'all, and as -- and 18 explained it to me, and as I attempted to visit around here 19 about it, just more and more questions kept popping up, and 20 I thought it would be -- the best way to do this thing is 21 for to us sit down around the table and just work through it 22 all. So, sir, take your liberty. 23 MS. DAVIS: Appreciate it. I hope you have 24 also had the opportunity to look at the answers that we 25 provided a couple of weeks ago, I guess, to a set of 7-13-05 jwk 3 1 questions from Commissioner Baldwin, and also, then, Judge 2 Tinley. 3 COMMISSIONER WILLIAMS: Mm-hmm. 4 MS. DAVIS: Two different sets. So -- and 5 what -- Buster, what I guess I propose to do this morning is 6 just run through this letter that was sent over in May by 7 Ron Patterson -- or drafted by Ron Patterson, and I think 8 Ron and David delivered it over here. 9 COMMISSIONER BALDWIN: Correct. 10 MS. DAVIS: And starting with the first 11 attachment, Attachment 1, and just go through those numbers 12 a little bit and make sure that everybody understands them. 13 And for our purposes this morning, I'm going to just 14 disregard that lefthand column, the column that's titled, 15 "No Subsidy," because that -- that's really not appropriate 16 in that the City is already subsidizing the operation. So, 17 let's start with the middle column, which represents this 18 fiscal year's budget, and includes a $129,000 supplement by 19 the City. As y'all note, we are beginning the year with 20 a -- or began the year with a $79,000 deficit, and we 21 estimated revenues of $1,659,070. We had a -- a transfer 22 into the operation, and, quite frankly, I can't remember 23 what that -- what that is, the $578. 24 Then the -- the next four numbers are 25 existing payments that are made by the City and the County. 7-13-05 jwk 4 1 Y'all know, I'm sure, that we split the payment along with 2 the City of Ingram. They pay a little stipend also to our 3 medical director, and his responsibility is to oversee the 4 protocols and help the EMT's and paramedics when they have 5 questions or need help, so I believe we pay him something 6 like $20,000 a year for that part-time service. The next 7 two numbers, again, are shared. That's the lease on the 8 facility out on Coronado Street, the $12,000. Then that 9 129, as I mentioned, is the City subsidy for this fiscal 10 year. And then the last number there is the $10,780 which 11 the County pays to our EMS Director to serve as the County's 12 director or manager of the First Responder program. Now, my 13 understanding is that that number was determined a few years 14 ago and represents 25 percent of what was then his salary. 15 Does that sound right? 16 COMMISSIONER BALDWIN: Yes, sir. 17 MS. DAVIS: Okay. All right. 18 COMMISSIONER WILLIAMS: What is the salary 19 now? Do you know? 20 MR. WAMPLER: Well, the 25 percent number 21 equals about $16,000 now, so whatever 16 times 4 is. So, in 22 other words, his salary's gone up, but the subsidy stayed 23 about the same. 24 COMMISSIONER LETZ: About 64,000. 25 MS. DAVIS: It's in one of these attachments, 7-13-05 jwk 5 1 Bill. I can't remember off the top of my head. 2 COMMISSIONER WILLIAMS: We'll get there. 3 MS. DAVIS: Okay. But David's right, that 4 since that was conceived, over the years, that increase 5 is -- or that 25 percent has increased by about $6,000. 6 Anyway, that gives us total funds available, as you see 7 there, the one million, 750. The operating expenditures are 8 listed there, and we're projecting an ending balance, again, 9 of $11,222 deficit. The 5 percent fund balance requirement, 10 the City has a policy whereby we try to provide a fund 11 balance of 5 percent on all of our funds. And the last 12 several years in the EMS fund, we have not been able to 13 achieve that, and it does not appear that we're going to be 14 able to do it this year either. That fund balance is really 15 kind of an emergency fund in the event that something 16 happens that's unforeseen, and that money is a contingency 17 and is available -- 18 COMMISSIONER LETZ: Question, just on how the 19 City operates on that. Do you all have -- you're all set up 20 with dedicated funds so that the -- like, if you need money, 21 you can't go in for -- say EMS, y'all can't go into the -- 22 you don't have a general fund? Or you have a general fund 23 and you have all these other funds? I mean, we have certain 24 -- we have a general fund, then we have certain dedicated 25 funds that can only be used for certain purposes. 7-13-05 jwk 6 1 MS. DAVIS: As we do, Jonathan. I don't 2 think we have the number that y'all do. And our major fund 3 is the general fund, and by Council action, moneys can be 4 moved from within that -- that general fund. Again, my 5 understanding is there's -- there is a policy -- and I'm not 6 sure, David, whether it's written or it's just kind of an 7 administrative policy -- that the department heads can, 8 within their operating department, move moneys around, as 9 long as the bottom line is not changed. Then the City 10 Manager and the Council -- well, the City Manager might do 11 some interdepartmental transfers, but the Council needs to 12 approve any interfund movement. So, there are dedicated 13 funds and some restricted funds, and we have a couple of 14 enterprise funds. But the biggest fund -- the two biggest 15 funds are the general fund and the water and sewer fund. 16 COMMISSIONER LETZ: I guess the reason for my 17 question is that, I mean, we have a -- a policy, but it 18 really applies to the -- to the -- our funds are divided up, 19 our dedicated funds, and a certain tax rate is attributed to 20 each one, and that's -- fees go into it or some source of 21 revenue that you can track. And we keep a general reserve 22 fund of a certain amount, of -- you know, our policy is no 23 less than 25 percent of our operating budget, essentially. 24 And I was just wondering how you do it, because if you -- it 25 seems that if you -- if we went by, you know, the Treasurer 7-13-05 jwk 7 1 needed to keep 5 percent and Rusty needed to keep 5 percent 2 and everyone needed to keep 5 percent, that you could end up 3 with a lot more money in that fund than you necessarily 4 need. I mean, I think -- so we just have a general policy, 5 we keep 25 percent. 6 MR. WAMPLER: We have it broken out by fund, 7 by budget. So, rather than having a single contingency fund 8 that's fed into by all the different budgets, we have a 9 5 percent contingency policy that is actually a written 10 policy. Now, what Don was saying in terms of the 11 flexibility within a given fund, the department heads do 12 have some flexibility, but for the interfund transfers, that 13 requires Council action to make that happen. 14 COMMISSIONER LETZ: Do y'all budget for this 15 5 percent? 16 MR. WAMPLER: Yes. 17 COMMISSIONER LETZ: So, you -- every 18 department has a 5 percent contingency? 19 MR. WAMPLER: Yes. 20 COMMISSIONER LETZ: That's different than our 21 reserve fund. 22 MR. WAMPLER: And, again, just to be clear, 23 that 5 percent contingency is a policy and it's a goal. In 24 this case, as you can see, we're not there. So, in other 25 words, if the numbers don't add up, we can't get there. I 7-13-05 jwk 8 1 mean, you know, we're not in violation, but it's actually a 2 policy -- a written policy that says that we will make every 3 effort to get there. 4 COMMISSIONER LETZ: Okay. 5 COMMISSIONER WILLIAMS: Is EMS, by your 6 definition, an enterprise fund, or is it different? 7 MS. DAVIS: No, it is not. I think it used 8 to be. 9 MR. WAMPLER: It used to be. 10 MS. DAVIS: Yeah. And, again, I think it was 11 like in 2001-2002 time frame when the operation started 12 losing money essentially, and we think most of that is 13 attributable to the fact of the Medicare -- what we call 14 disallowables. And, you know, they only pay a certain part 15 of that. Then, at that time, the -- the operation was moved 16 from an enterprise fund into the general fund. 17 MR. WAMPLER: An enterprise fund, Bill, would 18 be like the water and sewer fund. 19 COMMISSIONER WILLIAMS: Yeah. 20 MR. WAMPLER: As an example, we try to run -- 21 I say "we." The EMS budget had been run as an enterprise 22 fund for 10 or 15 years, and was one of the few EMS 23 services -- municipal EMS services in the state that was 24 self-sufficient for all of that time. But, as Don said, as 25 revenues started to decline, primarily due to Medicaid -- or 7-13-05 jwk 9 1 Medicare disallowables, you know, we moved it from 2 effectively an enterprise fund and had to start subsidizing 3 it from our general fund to -- to maintain it. 4 COMMISSIONER LETZ: And let me go back just a 5 little bit so y'all understand why I'm asking the question. 6 As I'm looking at this, it appears that somewhere in the -- 7 in these numbers up here for the next year, the County is 8 being asked to help get to that 5 percent fund balance. I 9 think that's a legitimate -- a fair way to do it if we're 10 fifty-fifty partners, but we're not here. This is a 11 contracted basis. I think that the City should be 12 responsible for keeping the fund balance wherever they want 13 it, and we should just pay for services. I don't know why 14 the County should have to pay for that 5 percent. That's -- 15 and maybe I just don't understand how it all works yet, but 16 that's just so y'all understand why I asked that question. 17 COMMISSIONER BALDWIN: That's a legitimate 18 question. It could be discussed. 19 COMMISSIONER LETZ: Sure. I mean, I'm not 20 saying -- 21 COMMISSIONER BALDWIN: Good discussion. 22 COMMISSIONER LETZ: Okay. We can go ahead 23 and probably go through it. 24 MS. DAVIS: All right. The -- the final 25 column that we see that is shown there on the right-hand 7-13-05 jwk 10 1 side, again, we're talking about beginning the year with 2 that $11,000 deficit, so we're not carrying forward the fund 3 balance into next year. We did project a 2 percent increase 4 in revenues, as you'll see. The -- the shared cost on the 5 medical director and the lease of the EMS facility stay the 6 same. We are anticipating an increase in the City's subsidy 7 up to 136,837, projecting a County subsidy of 136,837, and 8 then also a subsidy for a half of a -- of an ambulance. So, 9 the 37,500, if you add that, is obviously the $75,000. That 10 represents about half of one new ambulance, and you'll see 11 down in the expenditures, we have that as $150,000. The 12 reason that we only need to subsidize a half of that is that 13 the revenue generated from -- from non-emergency transfers 14 is sufficient enough to where it can pay for the other half 15 of the ambulance. In other words, we have a -- a little bit 16 of overage in that particular operation. 17 Then we show, again, the First Responder, 18 10,780 being the County's responsibility, giving total funds 19 available of 2,075,063. Again, in the operating expenses, 20 we have estimated a 4 percent increase in just our regular 21 operating budget. We do propose to replace one of the 22 ambulances for $150,000. Then we have the transfer out, and 23 I believe that is a payment that is made for two dispatchers 24 in the police department. So, here is one of these kind of 25 interfund transfers, so that that represents the cost of -- 7-13-05 jwk 11 1 of the communication and dispatching service that the EMS 2 uses. 3 COMMISSIONER WILLIAMS: Would that not fall 4 under your agreement with 9-1-1 for dispatching? 5 MS. DAVIS: We -- Bill, we do our -- our own 6 dispatching. The dispatchers at the police department 7 dispatch our police, fire, and EMS services. The only thing 8 that I'm -- I'm aware of on -- on the 9-1-1 is the -- the 9 money that's collected, I believe, through the telephone 10 company, if memory serves me, and -- and then that was used 11 to purchase some of the equipment, but not any of the 12 operational costs. 13 COMMISSIONER WILLIAMS: There's no 9-1-1 14 money that goes in for dispatching operations? 15 MS. DAVIS: I don't -- I don't think so. 16 COMMISSIONER BALDWIN: Yeah, there is. 17 JUDGE TINLEY: There's $36,000 a year -- 18 MR. DAVIS: Okay. 19 JUDGE TINLEY: -- over the last contract that 20 I saw that's paid for. 21 MR. DAVIS: I'm sorry, I don't know. I don't 22 know. 23 COMMISSIONER BALDWIN: And that's almost a 24 dispatcher. 25 MR. DAVIS: Yeah. Yeah. 7-13-05 jwk 12 1 COMMISSIONER BALDWIN: But that's correct 2 with his figure. 3 JUDGE TINLEY: That was the last contract I 4 saw. I don't know whether that had been renegotiated since 5 I saw that. 6 MR. DAVIS: I don't think so. 7 COMMISSIONER BALDWIN: I think that's 8 supposed to go toward a salary and some certain equipment 9 and those kinds of things, 36,000. 10 JUDGE TINLEY: It was a contract fee for City 11 of Kerrville Police Department to operate dispatch 12 operations for the PSAP for the 9-1-1 system. 13 COMMISSIONER WILLIAMS: That's the way I 14 recall it. 15 MS. DAVIS: Okay. Anyway, going down, you 16 see we have, again, that -- that 5 percent fund balance, and 17 that then is -- is projected balance for overall next year 18 of a dollar. And I will strongly recommend to the Council 19 that that balance be split with the County at the end of the 20 fiscal year, so we'll each end up with 50 cents. 21 (Laughter.) I'm sorry. No -- no levity here this morning. 22 All right. Anyway -- 23 COMMISSIONER WILLIAMS: A little bit. 24 MS. DAVIS: -- what this means is that the 25 total cost with this budget to the County for all of the 7-13-05 jwk 13 1 services would be 200,157, and that would include 189,000 2 for the EMS, and then the 10,780 for the First Responder, 3 and those numbers are in the very last sentence of the 4 footnote down there. Kind of -- that's kind of the bottom 5 line. But -- and it does represent the City and the County 6 splitting the deficit equally on a fifty-fifty basis. And 7 the way the subsidy was arrived at was by taking the 8 projected revenue and the deficit, adding in the costs that 9 are already shared, and then deducting from that the 10 expenditures and the fund balance, then simply dividing that 11 by two, and that's how we arrived at the 174,333 -- or 337, 12 which is half of -- of the projected deficit. Any -- any 13 questions on that schedule or the proposed budget? 14 Attachment 2 -- 15 JUDGE TINLEY: Excuse me, Mr. Davis. 16 MS. DAVIS: Okay. 17 JUDGE TINLEY: The bottom line of what I'm 18 hearing is the $200,157 is your calculation of what you 19 believe to be Kerr County's fair share of all EMS costs, 20 including First Responder and medical director and emergency 21 services? 22 MS. DAVIS: Yes, sir. 23 JUDGE TINLEY: The whole gamut of -- 24 MS. DAVIS: Yes, sir. 25 JUDGE TINLEY: Okay. 7-13-05 jwk 14 1 MS. DAVIS: Yes, sir. Okay, the second 2 attachment is just some -- kind of detail of some of the 3 statistical information that had been gathered. I believe 4 this was for the last year, and it shows kind of various 5 categories of -- of the percentage between the city and the 6 county on -- on the patients, the average call time. I 7 might add that that percent of loaded miles, we make a lot 8 of runs in which we'll go and the patient will decline 9 services for whatever reason, and so we then come back. 10 Now, we do have a charge for that; I believe it's $50. 11 Again, it's in one of those schedules. And -- but -- but 12 that's not included in our stat here of a loaded mile. In 13 other words, that's -- that statistic is only when we bring 14 a patient back in with us. 15 COMMISSIONER WILLIAMS: Do you have any feel 16 for how many, or the percentage of your trips that would 17 result in no loading? 18 MS. DAVIS: No, sir, I don't. And I'm not 19 sure -- I'm not sure if it's in one of these -- this backup 20 information or not. I don't -- I don't know. I got kind of 21 amused the other day; I was talking with Todd Bock about 22 this, and I showed him -- or he asked, and I said, "Well, we 23 charge $50 when we go out to make a run." He said, "My 24 gosh, I charge more than that for a mechanic on an RV when 25 they don't -- when I send them out and they don't do any 7-13-05 jwk 15 1 work." So, that's an area we may want to look at, you know. 2 I don't know. It's -- maybe that's -- maybe that's not 3 enough. 4 COMMISSIONER LETZ: How -- this is more kind 5 of a general question as to how you keep track of your data, 6 as to what questions we can -- or data we can ask for. Do 7 y'all keep track of where the -- I mean, obviously, where 8 the runs go, but how much in the -- can you give us a 9 breakdown of where in the county these runs are? 10 MR. DAVIS: I don't know, Jonathan. 11 COMMISSIONER LETZ: And the reason I'm 12 thinking on that is that the -- and I hope y'all are aware 13 that part of eastern Kerr County is about to probably go to 14 Kendall County, which would be the longest run times that 15 you probably have. 16 MS. DAVIS: Right. 17 COMMISSIONER LETZ: And that we -- and that 18 Precinct 4 has got rid of another section out near Kimble 19 County, so the long runs are probably going to go down in 20 the future, time-wise. I mean, parts of the county, just 21 because we're trying to handle those areas, or part of them 22 have been handled. And it appears that the eastern area of 23 Kerr County is going to go to Kendall County for primary -- 24 for primary call, though there will still be -- it's -- have 25 you met with Eric about what our discussions were? 7-13-05 jwk 16 1 MS. DAVIS: No. And I'm -- no, I haven't. I 2 have not. 3 COMMISSIONER LETZ: Well, the -- where we are 4 on that, last meeting that we had with Kendall County was 5 that if the Comfort ambulance is available -- well, all -- a 6 certain number of Comfort area phones, from a dispatch 7 standpoint, will be switched to Kendall County. They will 8 then dispatch the Comfort/Kendall County ambulance if it's 9 available. If it's not, they will manually call Kerr County 10 dispatch, and the ambulance will come out of Kerrville. So, 11 it's kind of a joint -- because Kendall County is not going 12 to get in a situation where they have both of their 13 ambulances -- one ambulance busy and the other one in Kerr 14 County; they only have pretty much two on call so that's 15 kind of the direction where it's going. So, it's going to 16 have an impact on dispatch, minimal. It's not that many 17 calls in this area, I don't think. 18 COMMISSIONER WILLIAMS: Is one of those 19 ambulances stationed in Comfort? 20 COMMISSIONER LETZ: Yes, most of the time. 21 So, anyway, that's kind of what we're trying to work out 22 there, but it'll -- it's going to be a hybrid from what we 23 did out in far west Kerr County. 24 MR. WAMPLER: To answer your question, 25 Jonathan, yeah, we -- the fire and EMS can tell you every 7-13-05 jwk 17 1 run, the time on the run, the -- you know, the address and 2 all, but I don't think that it shows that in terms of 3 graphing it or charting it on the county map, or -- 4 COMMISSIONER LETZ: 'Cause I think what would 5 be interesting would be, you know, I guess the percent of 6 the runs that are -- you know, how many of them are right 7 around Kerrville, which I would think that a lot of the runs 8 are because of the population makeup. Most of them are 9 really no further than inside the city limits. I mean, 10 they're -- you can get to Kerrville South or areas at 11 Whiskey Canyon -- 12 COMMISSIONER BALDWIN: Or you could just use 13 the ETJ. There's some areas that are basically the same run 14 time. But, obviously, if you get out into, you know, some 15 of the areas around Hunt or Center Point, obviously, those 16 are going to be longer run times. 17 MS. DAVIS: Right. 18 COMMISSIONER LETZ: And I think distribution 19 is important. 20 COMMISSIONER WILLIAMS: Or you could take an 21 average of run time of all city -- all city calls. 22 COMMISSIONER LETZ: Right. 23 COMMISSIONER WILLIAMS: All within the city 24 or ETJ. What's the average run time of all of them? And 25 anything that exceeds that is -- 7-13-05 jwk 18 1 COMMISSIONER LETZ: Well, they have the 2 average of the city -- I think they have those. It's just 3 trying to get a feel for how many of them are long runs in 4 the county versus how many of them are ETJ-type runs. 5 MS. DAVIS: The -- and David's right. I 6 mean, we've got all that information. I guess it's just a 7 matter of, you know, trying to make some -- 8 COMMISSIONER LETZ: Try to figure out. 9 MS. DAVIS: And we could spend probably three 10 or four man years just running stats on this thing. 11 COMMISSIONER LETZ: Right. 12 MS. DAVIS: I think the significance of this 13 is that, you know, you -- looking at this in a myriad of 14 different ways, the City's position was, you know, it looks 15 as if that it's a -- probably the most logical would be just 16 to split it fifty-fifty as far as -- as the subsidy, so 17 that's what's proposed with this document. And then 18 Attachment 3, of course, is a proposed interlocal agreement, 19 which the base year -- the initial year is coming up, 20 October 1 through September 30. There's some termination 21 provisions in there that -- that either side can mutually 22 terminate at any time, and there's some 90-day written 23 notices, and then some provision in there when a party has 24 breached their obligations in the contract. Then it goes on 25 to say that -- that the agreement can be renewed for a 7-13-05 jwk 19 1 one-year period following the initial period. It sets out 2 the level of services that will be provided by the City, and 3 my understanding is that these just kind of mirror what 4 we're doing now. I don't think there's any drastic change 5 one way or the other in the level of service. Part of this 6 is maintaining two ambulances, you know, that's available. 7 There's some reporting requirements, and then the payment 8 provision, Section 3, calls for the numbers that we just 9 went over. And then, if it goes into a second year, there's 10 a provision for an annual increase of whichever is greater, 11 5 percent or a formula that takes into account the C.P.I. of 12 the medical industry as well as the transportation industry. 13 And I think that's about it as far as the contract. As far 14 as I was concerned, those were the salient kind of points in 15 the contract. Buster, I didn't know whether y'all wanted to 16 get into these questions and answers? Or, at this point, I 17 guess I'll leave it up to you as to how we want to go. 18 COMMISSIONER BALDWIN: Sure. 19 COMMISSIONER LETZ: I didn't bring my 20 question and answer pages. I read them a long time ago, and 21 then they were kind of -- 22 MR. WAMPLER: You can have those. 23 COMMISSIONER BALDWIN: I think there is 24 several of us at the table that do have -- do have 25 questions. 7-13-05 jwk 20 1 COMMISSIONER NICHOLSON: Commissioner, could 2 I talk a little bit about strategy before we get into the 3 details of the -- 4 COMMISSIONER BALDWIN: Sure. 5 COMMISSIONER NICHOLSON: -- content? I see 6 that some services that governments pay inure the benefit of 7 a small percentage of the population, and sometimes those -- 8 that population can be identified. And this might be one of 9 those -- it might be one of those that fits the user-pay 10 sort of strategy. And I see we're providing medical 11 service, and that we do like doctor's offices do and like 12 hospitals do, and their strategy -- and they deal also with 13 things like bad debt and Medicare disallowables and HMO's 14 and all the reasons why they might not get paid what their 15 services cost. But their strategy appears to be one that 16 charges an amount that takes into account that there'll be 17 bad debt and HMO's, all that stuff. And while we may not 18 like it, when I go to the doctor's office and pay the amount 19 I pay, I'm paying for deadbeats and for HMO's and bad debt, 20 but my doctor doesn't just break even; he makes a living by 21 charging an amount to all the rest of us that will more than 22 cover his costs. And I presume hospitals charge an amount 23 that acknowledges these losses that -- 24 COMMISSIONER WILLIAMS: They do. 25 COMMISSIONER NICHOLSON: Where they at least 7-13-05 jwk 21 1 break even, I think. I don't know that. But that leads me 2 to think that we ought to have a strategy that -- that's a 3 user-pay strategy; that we ought to adjust our fees in a way 4 that eliminates the losses that we incur on providing EMS. 5 MR. WAMPLER: Dave, I don't know if we've 6 looked at that in great detail, but I can tell you that the 7 reason that we are in the situation that we're in are two 8 things. I think the majority of our runs are 9 Medicare-reimbursable, Medicare-eligible runs, and so I 10 don't know what the percentage would be, but let's say for 11 the sake of argument that 80 percent -- this is entirely 12 hypothetical -- 80 percent of our runs are 13 Medicare-eligible, and 20 percent would be private-pay or 14 some other insurance pay. If -- if that were the case, I 15 think the burden, potentially -- the incremental cost 16 increase that you'd have to put on the 20 percent to 17 subsidize the 80 percent would be pretty high. Again, I 18 don't know if we've looked at that, but the fact is, as I'm 19 sure you know, on the Medicare side we're -- we're not 20 allowed by law to bill that difference. In other words, we 21 have to take that Medicare reimbursement, and we can't go 22 back to the patient and try to collect the balance that's 23 owed. 24 COMMISSIONER WILLIAMS: Medicare or Medicaid? 25 MR. WAMPLER: Medicare. I mean, I don't know 7-13-05 jwk 22 1 what the percentage is, but it's more than 50 percent of our 2 runs are Medicare-eligible runs. 3 MS. DAVIS: I think I have that, and I'm 4 looking for it somewhere. 5 COMMISSIONER WILLIAMS: I thought you could 6 go back and bill on Medicare, but not on Medicaid. 7 MR. WAMPLER: I know in the medical 8 environment, you can't do that at all. 9 COMMISSIONER WILLIAMS: You'd know. You're 10 closer to it than I am. 11 MS. DAVIS: Well, let me -- 12 JUDGE TINLEY: I'm looking at some analysis 13 collection rates, and it shows of -- of 100 percent of 14 billings of '03-'04 fiscal year, billings are almost 15 $2 million, to -- to include 100 percent. Disalloweds are 16 slightly -- are about 25 and a half percent. That would 17 include the private-pay as well as the Medicare disalloweds, 18 would it not? 19 MR. DAVIS: I'm sorry, I wasn't listening. 20 I'm drawing over here. I was trying -- I wanted to come up 21 with -- try to illustrate -- 22 JUDGE TINLEY: Here's where I'm coming from. 23 This was in response to some questions that I had. 24 COMMISSIONER WILLIAMS: Which page are you 25 on? 7-13-05 jwk 23 1 JUDGE TINLEY: The page is not numbered, but 2 it -- 3 MR. DAVIS: Yeah, I'm sorry about that. 4 JUDGE TINLEY: -- it's under Item 7. And, I 5 don't know, about Page 5. Excuse me, Item 9, overall 6 collection rate for EMS service. 7 MS. DAVIS: Mm-hmm. 8 JUDGE TINLEY: It shows '03-'04, which is the 9 most recent entire fiscal year that we've got, total 10 billings of just under a million, nine-plus as 100 percent 11 billings. Disalloweds are -- are a little over 25 percent 12 of that, so that would include all the disalloweds, be they 13 Medicare, Medicaid, private HMO's, whatever? 14 MS. DAVIS: No, that would just be 15 Medicare/Medicaid. 16 JUDGE TINLEY: Okay. 17 MR. DAVIS: The actual disalloweds. 18 MR. WAMPLER: Yeah. When we refer to 19 disalloweds, we're actually referring to government entities 20 short-paying our bills, so that doesn't include bad debt or 21 any other, you know, insurance or -- 22 JUDGE TINLEY: That doesn't include what -- 23 is there a right of recourse against the balance for -- 24 MR. WAMPLER: No. 25 COMMISSIONER WILLIAMS: Item 6 delineates 7-13-05 jwk 24 1 that. It talks about -- 2 MR. WAMPLER: Right. 3 COMMISSIONER WILLIAMS: -- the Medicaid 4 disallowed and the Medicare disallowed. 5 MR. WAMPLER: Right. 6 MS. DAVIS: Let me try to illustrate. And 7 these numbers aren't right, but it's just simple math, I 8 guess. But, as an example, if -- if a run is $400, an 9 average-cost run, the government says that Medicare/ 10 Medicaid -- that the rate that they will pay is $300, and 11 they have predetermined what the service out here in the 12 Hill Country is for emergency medical services. So, $300; 13 then they pay 80 percent of that. In this illustration, 14 that would be $240. Now, what we can try to do is we can 15 try to collect that $60, the difference between their 16 80 percent and -- and the 100 percent, and this is often 17 done by supplemental insurance on Medicare, or just -- we'll 18 actually bill the patient. But when we enter into an 19 agreement with the government to receive the Medicare, we 20 agree that we will not ever try to collect that amount -- 21 that part. So, it's this $100 in this illustration that we 22 call disallowables. 23 COMMISSIONER NICHOLSON: So, the strategy I 24 was talking about would, for example, require us to get out 25 of the Medicare contract. And that's what some health 7-13-05 jwk 25 1 providers do. My doctor won't accept Medicare. He bills me 2 the full amount of services, and -- 3 MS. DAVIS: And his fees probably went down, 4 I would imagine. But, yeah, you could raise that rate, 5 David. But you can't -- you know, you don't have any 6 control over their ceiling, so -- 7 MR. WAMPLER: That's actually a moving 8 target. That's changed over the years, and will probably 9 continue to change. 10 JUDGE TINLEY: Is not the rule, rather than 11 100 percent of Medicare allowables, 115 percent? 12 MS. DAVIS: I don't know. 13 JUDGE TINLEY: I'll give you a for instance. 14 I've been under the Tricare program, which, of course, is 15 very similar to the Medicare program. And the -- if I'm not 16 mistaken, of course, they pay a certain percentage under 17 Tricare Basic, and then they can -- the doctor or provider 18 can collect up to 115 percent of what Medicare allows, or in 19 this case Tricare, for that specific procedure, the 300 in 20 your example. 21 MS. DAVIS: So, that would be up here 22 somewhere. 23 JUDGE TINLEY: Yeah, that would be $345, for 24 example. So you could collect the difference between 240 25 and 345. 7-13-05 jwk 26 1 MS. DAVIS: I don't know. But -- 2 JUDGE TINLEY: I -- that's what my 3 understanding was here a couple of years ago. Now, as 4 Mr. Wampler said, that's a moving target, and I'm sure the 5 rules change. 6 MR. DAVIS: We'll check on that, because if 7 that, in fact, is the case and we're not doing it, then we 8 need to be, absolutely. 9 COMMISSIONER NICHOLSON: What I'd like to 10 create is a model -- economic model that says, "Here's what 11 our fees would have to be to break even." It might be with 12 Medicare or might be without Medicare, and transfer that -- 13 that cost to the users. 14 COMMISSIONER WILLIAMS: Don't we have a 15 utilization statistic that shows Medicare versus private 16 pay? Don't we have a statistic that shows that percentage 17 of -- percentage of patient load that is either 18 Medicare/Medicaid covered as opposed to private-pay covered? 19 COMMISSIONER LETZ: Page before that. 20 MS. DAVIS: I think we do. 21 COMMISSIONER LETZ: The page before that. 22 MS. DAVIS: May be this source of payment. 23 That's Item 6 under -- 24 COMMISSIONER WILLIAMS: Item 6? 25 MR. DAVIS: -- Judge Tinley's letter, that -- 7-13-05 jwk 27 1 COMMISSIONER WILLIAMS: Yeah. 2 MS. DAVIS: -- you need to add up -- you 3 know, there's several Medicare. Here's -- 4 COMMISSIONER WILLIAMS: Well, 21 percent. 5 JUDGE TINLEY: That's the income -- well, no, 6 that's -- that relates to the total -- some of it is not 7 payment. Some of it -- 8 MR. DAVIS: No, it's not payment. It's just 9 the source of the payment. 10 MR. WAMPLER: The source of the payment. 11 MR. DAVIS: Yeah. And I -- 12 MR. WAMPLER: So, if you add the Medicare 13 check, Medicare disallowed, Medicaid, Medicaid disallowed, 14 and then go down to Medicaid check, electronic funds 15 transfer and add those up, that's -- you know, those are all 16 the source of payments that we receive. 17 MS. DAVIS: Over 40 percent. 18 COMMISSIONER WILLIAMS: Well, personal check, 19 business check, private insurance check, private insurance 20 disallowed -- 21 MR. WAMPLER: Right. 22 COMMISSIONER WILLIAMS: -- becomes the other 23 side of that -- 24 MR. WAMPLER: Exactly. 25 COMMISSIONER WILLIAMS: -- equation. Is that 7-13-05 jwk 28 1 correct? 2 MR. WAMPLER: Right. 3 COMMISSIONER LETZ: Going back to Item 9, the 4 chart -- 5 MS. DAVIS: On which? 6 COMMISSIONER LETZ: On Judge Tinley's 7 responses, the next page. 8 MS. DAVIS: Okay. 9 COMMISSIONER LETZ: Okay. I understand the 10 billings. Obviously, disalloweds, I understand. Allowed 11 collectibles. So that's how much we can go after? 12 MS. DAVIS: Right. 13 COMMISSIONER LETZ: Bad debt write-off, 14 16 percent, which is 315,000. That seems like a high number 15 to me, that that much is written off. Is that not high? I 16 mean -- 17 MS. DAVIS: I would say, industry-wide -- and 18 I can't quote you a number, Jonathan, but I'd say that's 19 probably pretty low, really. And if you take -- I made 20 myself a note here. If you take what we do collect out of 21 what is eligible to collect, we're collecting about 22 78 percent. And, again, I think, industry-wide, that's -- 23 that's a good collection. Now, let me tell you kind of the 24 process, as I understand it. We -- we'll send out a letter 25 and follow up on -- with these people that we bill, and then 7-13-05 jwk 29 1 after one or two letters, we actually turn that over to a 2 collection agency and they try to work it for us. So, I'm 3 not real sure what more can be done. David and I visited 4 briefly yesterday about the fact there are a lot of 5 companies that -- that -- in the medical industry that do 6 the billing and collecting for doctors, hospitals, clinics 7 and emergency medical providers, and I think that's 8 something we may want to look at. You know, I don't -- 9 probably not right now, because we just got some other 10 priorities we need to do, but maybe this winter sometime, 11 just to see if we can increase our collection rate at a 12 lower cost. And, certainly, if that's the case, I think 13 that would be something we could do. 14 COMMISSIONER LETZ: Does the City have a 15 collections department, before you turn it over to a 16 collection agency? 17 MS. DAVIS: Yes. 18 MR. WAMPLER: Yeah, we have a dedicated EMS 19 clerk. Collection billing system, yeah. 20 MS. DAVIS: Yeah. 21 JUDGE TINLEY: The one out of the Coronado 22 office there? 23 MR. WAMPLER: Yes. 24 COMMISSIONER WILLIAMS: Couple comments here, 25 gentlemen. I really want us to work out an equitable 7-13-05 jwk 30 1 situation. I want the County to continue to contract with 2 the City for these services, but I'm having a difficult 3 time, honestly, getting past the initial stats, the 4 utilization statistics which show that within the city 5 limits, 76 percent, by your analysis, are city runs, and 6 outside, which would be county runs, is 20 percent -- 7 they're fractions in each case, but just for the sake of 8 discussion -- leaving about 4 percent for others, which 9 would be Ingram and whatever, or outside the county. 10 Outside of the county's going to disappear; that's .8 11 decimal percent. So, I'm having a hard time wrestling with 12 the utilization statistic. I believe we should pay our fair 13 share, and if we -- if we agree that there needs to be a 14 county subsidy for disallowables, those disallowables need 15 to be our fair share of what takes place in the county, as 16 opposed to a piece of what takes place in the city. So, you 17 got to help me get over that. 18 MR. WAMPLER: Bill, go back. And you said 19 76 percent? Tell me -- 20 COMMISSIONER WILLIAMS: Well, I'm looking at 21 this -- the one that came from Brian Brooks. It's called 22 EMS -- it came from Brian June 10th; was sent to 23 Commissioner Baldwin. It's page 7A. 24 MR. WAMPLER: All right. 25 COMMISSIONER WILLIAMS: I can also look at 7-13-05 jwk 31 1 yours. 2 MR. WAMPLER: I gave mine to Jonathan. 3 COMMISSIONER WILLIAMS: Yours says 26, but 4 there's still a pretty huge disparity there. 5 MR. WAMPLER: So you're looking at run count. 6 To answer your question, in one way -- as Don said, there 7 are a lot of ways to look at the data. There's number of 8 patients. There's loaded miles. 9 COMMISSIONER WILLIAMS: Mm-hmm. 10 MR. WAMPLER: There's total mileage, to name 11 three. And what we're looking at is actually utilization of 12 the resource. And if you -- if you call the resource the 13 actual personnel and the vehicles and the time that they're 14 on a call, the mileage -- or whether it's the mileage or the 15 time, that's what we're trying to take a look at. We're not 16 looking at -- I mean, you're right; if you look at the 17 number of patients, the actual number of bodies taken to the 18 hospital or the people that are tended to, there is a 19 disparity. But if you look at the -- the mileage that we're 20 putting on both the personnel and the vehicles to handle 21 calls in the county -- and, admittedly, Jonathan makes a 22 decent point, that whether they're in the ETJ or whether 23 they're in far west Kerr County or far east Kerr County, we 24 haven't sliced that. We've said if they're in the county, 25 which we have done that analysis. We're looking at the 7-13-05 jwk 32 1 total number of miles, which comes out to about 50 percent. 2 COMMISSIONER WILLIAMS: Let's take a look at 3 personnel -- and picking up on your point, personnel and 4 mileage. Personnel, for all practical purposes, is a fixed 5 cost. It's part of your fire department and so forth; 6 that's part of it. And if you want to take an extension 7 even beyond that, the City -- the County pays a piece of 8 that by reason of our fire contract, so we got -- we got a 9 bite of the personnel cost already. 10 MS. DAVIS: No, Bill, that's not right. 11 MR. WAMPLER: Actually, that's not true. 12 MS. DAVIS: It's two separate departments, 13 and we account for them differently. 14 COMMISSIONER WILLIAMS: Personnel are 15 interchangeable. 16 MR. DAVIS: Our people are cross-trained. 17 Now, some of which have -- you know, if you and I are 18 primarily assigned to the ambulance operation, our salary is 19 in the ambulance department, you know, so we do keep 20 accounting separate for these people. 21 COMMISSIONER WILLIAMS: Okay. Even given 22 that, are there any statistics that would show that the runs 23 into the county, which, again, is a smaller percentage of 24 the whole -- 25 MR. WAMPLER: In terms of numbers of runs. 7-13-05 jwk 33 1 COMMISSIONER WILLIAMS: Number of runs. Are 2 there any statistics that -- that would show or indicate 3 that overtime was involved for these personnel because of 4 that? 5 MR. WAMPLER: The way we're looking at it, 6 Bill, is that we have to maintain a staffing and equipment 7 level to serve all of the constituency that we're serving, 8 including the county right now. That is a fixed cost. 9 COMMISSIONER WILLIAMS: Right. 10 MR. WAMPLER: If we weren't serving the 11 county -- and I can't tell you what it would be, but those 12 fixed costs could be eliminated to some extent, or could be 13 reduced to some extent if -- if our population and area size 14 was reduced. So, there is a fixed cost associated with 15 serving that wider area that we maintain all the time. 16 And -- and so, rather than saying to the County, "We have a 17 $1.7 million budget, including that fixed cost, to provide 18 the service to all of the county and the city, and, you 19 know, 50 percent of that resource is used outside of the 20 strict city limits of the city of Kerrville, so therefore 21 you should pay for half of that budget," we're not saying 22 that. We're saying that we have done this as an enterprise 23 fund for many years, and due to circumstances beyond our 24 control, we're running a deficit. 25 COMMISSIONER WILLIAMS: Mm-hmm. 7-13-05 jwk 34 1 MR. WAMPLER: And we're asking for -- based 2 on the time and the mileage spent serving needs outside of 3 the city limits, we're asking for 50 percent of that deficit 4 to be covered. 5 COMMISSIONER LETZ: But let me -- 6 COMMISSIONER WILLIAMS: Deficit? Let me ask 7 one question. 8 COMMISSIONER LETZ: Okay. 9 COMMISSIONER WILLIAMS: But the deficit -- 10 let's deal with the deficit. The deficit is predicated on 11 the whole. 12 MR. WAMPLER: Mm-hmm. 13 COMMISSIONER WILLIAMS: The number of 14 patients and the whole load. 15 MR. WAMPLER: Mm-hmm. 16 COMMISSIONER WILLIAMS: Right? And if the 17 County's stat is, say, 20 percent of the whole or somewhere 18 in that vicinity, you're saying that we should make up the 19 other 30 percent to get us to parity on the deficit, and I 20 don't -- I don't follow that. 21 COMMISSIONER LETZ: I guess what -- I'm 22 following up on Bill's -- it seems like the City is basing 23 this on miles. Well, I think the -- you know, I think it's 24 closer to being accurate to base on it calls. And the 25 reason is, dispatch is a great example. We're adding in 7-13-05 jwk 35 1 $76,000 in dispatch costs to the county. There's no more 2 dispatch for a call that takes -- that goes to anywhere, I 3 mean, outside, and that's a fixed cost. I mean, that's more 4 per call, so, clearly, I can see that there should maybe be 5 an adjustment based on miles or mileage on the vehicles. 6 COMMISSIONER WILLIAMS: Mm-hmm. 7 COMMISSIONER LETZ: But I think the -- the 8 fairer way to do it is look at the number of calls, which 9 is -- on this chart, is 69 percent in the city and 10 26 percent in the county. The other numbers that we had are 11 a little bit -- like, 72 percent or whatever it was in the 12 city and 20 percent in the county. And then I think it's 13 fair to look at that and then say, okay, granted, there's 14 the usage, and then a higher -- you know, there's a 15 surcharge to the County because the calls in the county are 16 obviously further. 17 JUDGE TINLEY: That's the reason -- 18 COMMISSIONER WILLIAMS: On mileage as well as 19 vehicle maintenance. 20 COMMISSIONER LETZ: Yeah, on the whole 21 equipment side. I mean, on the equipment side, the County 22 pays a surcharge. 23 JUDGE TINLEY: Well, but that was one of the 24 reasons I asked about portions of revenues derived from 25 various segments of the charges imposed. There's a base 7-13-05 jwk 36 1 rate which applies whether they're driving across the street 2 or driving 100 miles. 3 COMMISSIONER WILLIAMS: Mm-hmm. 4 JUDGE TINLEY: Now, once they pass a given 5 mileage portion -- and I don't know exactly what that is, 6 but once they reach a certain plateau, they start to accrue 7 additional mileage charges. And I asked the portion of 8 total revenues derived from basic mileage or basic charges, 9 patient pickup and additional mileage charges. The 10 breakdown -- I'm not sure how they've arrived at the 11 percentages. That's in Number 3. The base rate was a 12 million, 567. Then we just have mileage, whether or not -- 13 I don't know whether that's basic mileage charge or 14 additional mileage charge, or just what's shown on mileage 15 in the billing that comes out. I don't have that. That's 16 540, which would be, what, approximately a third, I guess, 17 of -- of that. That was the basis for my question, is 18 what -- what's generated, whether they're driving across -- 19 across the street or across the county, and then what 20 additional charges come into play and what percentage of -- 21 of charges are generated from that? And -- and I think 22 that's a telling picture, and it somewhat relates to what 23 we've -- what we've got here on the utilization analysis. I 24 didn't see the figures that Bill had about 76. That's 25 different from the system analysis -- utilization analysis 7-13-05 jwk 37 1 that was provided initially that shows 69 percent and 26. 2 And of course those don't add up to be 100, but Ingram's out 3 there, so that will probably account for the difference. 4 COMMISSIONER LETZ: It just looks to me -- 5 it's hard to justify going to a fifty-fifty split when 6 basically 25 percent of the calls are in the county. I 7 mean, I just -- I don't see how you can get there, because 8 there's not -- 9 MR. WAMPLER: Well, the average length of the 10 call in the county is greater than the average length of the 11 call in the city, but the utilization of the truck is longer 12 on average. 13 COMMISSIONER LETZ: But the dispatch is a 14 fixed cost. The employee time, salaries, all that's a fixed 15 cost. The basic equipment is a fixed cost. The only thing 16 that's costing more is the excess -- or the more usage of 17 the vehicles in the county. 18 MR. WAMPLER: And that fixed cost associated 19 with having the staffing necessary to cover the entire 20 county is increased due to the fact that we're covering the 21 county. Our fixed costs if we were only covering the city 22 of Kerrville would be less. 23 COMMISSIONER WILLIAMS: Could you reduce your 24 staff 20 percent if you weren't -- 25 MR. WAMPLER: I don't know what the number 7-13-05 jwk 38 1 is, but I assume we could. 2 COMMISSIONER LETZ: They're saying reduce it 3 50 percent. You should be able to reduce -- 4 MR. WAMPLER: I don't know what the number 5 is. 6 COMMISSIONER LETZ: I'm saying under that 7 argument, though, you could reduce that 50 percent if the 8 county wasn't here, and I don't see that you can reduce your 9 staff 50 percent in your EMS, from what I see. 'Cause, I 10 mean, that means you'd have to go to one ambulance, and I 11 don't think that Kerrville could do that. My other question 12 is -- and, you know, I think you understand where we're 13 coming from on this. And the other question I have, though, 14 is all of this looks like it is -- someone calls 9-1-1, 15 there's -- and you go out and send an ambulance. What about 16 the usage of -- is that in here? The usage of transport 17 from Sid Peterson to -- 18 MR. WAMPLER: San Antonio? No, it's a 19 separate -- 20 COMMISSIONER LETZ: Well, 'cause I think that 21 also needs to be put in the mix, because as I understand it, 22 that is the -- the gravy, if there is any gravy in EMS, is 23 those transports, 'cause you know you have insurance and you 24 know you're going to get paid. And those need to be figured 25 in here, because the fixed costs of the department and the 7-13-05 jwk 39 1 machinery and the wear and tear and all that is used. 2 MS. DAVIS: It is, Jonathan. And I -- 3 MR. WAMPLER: Maybe I misspoke. 4 MR. DAVIS: I don't mean to correct the 5 councilman, but yes, those numbers are in the budget, the 6 revenue that's generated. 7 COMMISSIONER LETZ: I don't mean in the 8 revenue; I mean in these figures here. 9 MS. DAVIS: All right. Now, the transfers, 10 as I understand this report, are not included. 11 MR. WAMPLER: Transfers are not here, but 12 they are included in the dollars. 13 MS. DAVIS: But, yes, that's correct. 14 COMMISSIONER LETZ: But what I'm saying is, 15 you need to look at that time and that usage and that loaded 16 miles, because that is a -- the County, I mean -- 17 MR. WAMPLER: We have a dedicated transfers 18 box; it's an older ambulance, so the transfer box is not -- 19 unless it's an emergency where we have all of our ambulances 20 out. 21 COMMISSIONER LETZ: Right. 22 MR. WAMPLER: That -- that transfer ambulance 23 is a dedicated transfer ambulance. 24 COMMISSIONER LETZ: Okay. 25 MR. WAMPLER: So, do you see what I'm saying? 7-13-05 jwk 40 1 And we made adjustments for that two years ago. So, you 2 know, not to say that if we had all of our ambulances out 3 and the transfer box is available, we wouldn't send on it a 4 county or city run. We would. But under normal operations, 5 that's a dedicated transfer ambulance. 6 COMMISSIONER LETZ: But what about the 7 staffing, I guess? I mean, are any expenditures associated 8 with that ambulance coming in here? I mean, the revenue 9 needs to be included if the expenditures are included 10 anywhere. 11 MS. DAVIS: And they both are. 12 COMMISSIONER LETZ: Okay. 13 MR. WAMPLER: I mean, yeah. We don't have a 14 dedicated transfer staff. We do have a dedicated transfer 15 ambulance, though. 16 COMMISSIONER LETZ: Okay. 17 MS. DAVIS: But the numbers are not included 18 in this analysis, because this is just based on the 19 emergency -- 20 COMMISSIONER LETZ: Right. But, I mean, some 21 -- and I -- it's legitimate to not include the miles if it 22 is a dedicated ambulance. 23 MS. DAVIS: Right. 24 COMMISSIONER LETZ: That's fair. 25 MR. WAMPLER: I mean, just to be clear -- and 7-13-05 jwk 41 1 I know we're beating a dead horse at this point -- these 2 numbers are based strictly on calls for service associated 3 with 9-1-1 calls saying, "I need an ambulance." It doesn't 4 have -- the transfers are not built into these numbers at 5 all. 6 COMMISSIONER LETZ: These -- I'm sure it's in 7 the front. What year -- this is '03-'04? 8 MS. DAVIS: I think so. That's my 9 understanding, Jonathan, yeah. 10 COMMISSIONER WILLIAMS: Let's see. 11 MR. WAMPLER: I guess, speaking of that, we 12 have -- this is a relatively new item. This is more up to 13 date, these kind of charts, disallowables and how it's 14 grown, you know, since '96. And it's actually dropped off a 15 little bit. That's where I referred back to the fact that 16 it's a moving target. I didn't come back and look, 17 obviously, on an annual basis to see where we're at, but, I 18 mean, this is up to -- you know -- 19 COMMISSIONER LETZ: Does the city -- or is 20 the City in the process of, for this budget year, really 21 looking at your pay structure? I know other counties around 22 here are doing that, 'cause everyone, I think, has the 23 same -- 24 MR. WAMPLER: We haven't gotten into that 25 from a budget standpoint, but that's something that we've 7-13-05 jwk 42 1 identified that we need to continue to look at. And I'll 2 tell you that previous to five or six years ago, our pay 3 structure, both in the fire department and EMS and police 4 department, were -- we were essentially training ground. 5 COMMISSIONER LETZ: I don't mean salaries; 6 I'm thinking more service. You know, I think it was a -- 7 someone said it was $50 a run to send an ambulance out. I'm 8 kind of like -- I think it was Ron that made the comment 9 that, "I wouldn't go anywhere for 50 bucks." 10 MR. WAMPLER: I think that's something we 11 need to take a look at, absolutely. 12 COMMISSIONER LETZ: And I think -- I don't 13 know how much of an impact that has on the revenue side, but 14 I think that can easily be certainly doubled. 15 COMMISSIONER WILLIAMS: This is kind of a 16 view of what's happening -- 17 MR. WAMPLER: Yes, sir. 18 COMMISSIONER WILLIAMS: -- today? 19 MR. WAMPLER: That's just a graphical 20 illustration of what disallowables have done and why, fairly 21 suddenly, you can look at the -- you know, at 2001-2002 when 22 we removed EMS from an enterprise fund where it was 23 self-sufficient, you know, we can see a pretty significant 24 spike in what the government was willing to pay versus what 25 we needed to recoup or charge for our services. And, as I 7-13-05 jwk 43 1 said, you can see at the top, we can't -- we don't know why, 2 but it's actually started to drop off a little bit. Now, 3 presumably, the government's reimbursing a little more than 4 they had in the past. 5 COMMISSIONER LETZ: It seems to me, since 6 this is a workshop, we're kind of at a -- a stopping point 7 in a way. I mean -- I mean, I think that the -- what I'm 8 hearing is that -- our side, is that we think that the way 9 the City come up with the breakup of fifty-fifty based on 10 more on mileage isn't fair, because there's lots of costs in 11 there that have nothing to do with us, such as fixed costs 12 of salaries and the -- and the equipment and dispatch and 13 all that clearly are not a fifty-fifty split, because it's a 14 -- those are usage numbers. But that there is a feeling 15 that there is a surcharge which would be appropriate from 16 the -- for the mileage and longer distances in the county. 17 You know, and I don't think that you all can answer that, 18 because, obviously, you're talking about one councilman and 19 a City Manager. You know, I think the -- my feeling is to 20 ask y'all to go back and look at that. Whoever -- I don't 21 know if this is a City Manager decision or a Council 22 decision; I don't know where that came from, but I just -- I 23 don't -- it doesn't seem fair to me. It seems that the 24 County's being asked to pay more than its fair share. Quite 25 a bit more. 7-13-05 jwk 44 1 COMMISSIONER NICHOLSON: Jon, I -- from what 2 I've learned from this and what I'm hearing everybody say, I 3 agree with you, that I don't know what our fair share is, 4 but it looks like it's something less than 50 percent. 5 COMMISSIONER LETZ: And a lot more than 6 what -- where we are right now. I mean, clearly, we're not 7 paying our fair share now. 8 MR. DAVIS: Well -- 9 COMMISSIONER WILLIAMS: I agree, we're not. 10 MR. DAVIS: Gentlemen, I think the three 11 important things that we have here is the -- the percentage 12 of the loaded miles; that's the -- when we're carrying 13 patients, and then, to me, the average call time, and then 14 the -- the percentage of those last three statistics, all of 15 which are right around that 50 percentile, or 50 percent 16 split. But the calls -- we're not going to staff up based 17 on the number of calls, because it just -- I mean, that's 18 almost an immaterial statistic. What's important from a 19 staffing standpoint is the time that we're spending 20 providing the service and the cost of that in terms of, you 21 know, manpower and equipment, which gets back to time and 22 miles. 23 COMMISSIONER LETZ: But how can you justify 24 us paying additional -- I mean, 50 percent of -- or two 25 additional for dispatch? I don't see how that fits into 7-13-05 jwk 45 1 this. I mean, how does dispatch costs increase because 2 you're out on a run longer? 3 MR. DAVIS: Well, a certain -- there is a 4 certain cost to provide this service that includes the 5 dispatching, and that's why that number -- the 74,000 or 6 whatever that number is, in order to reflect that cost to 7 this service, you have to include it. And you're exactly 8 right; you know, the dispatcher receiving the call and 9 dispatching the -- the unit, whether it's in town or out of 10 town or in Gillespie County, that -- you know, that doesn't 11 affect what the amount of time that she or he spends on that 12 deal. But all -- all we have determined here is that, based 13 upon, again, time, that the $74,000 representing, I think, 14 approximately two dispatchers, if this were a stand-alone 15 operation, we'd have to have two dispatchers to cover the -- 16 the communication needs of that -- of the ambulance. 17 COMMISSIONER WILLIAMS: But, Don, it's not -- 18 it's an integrated operation, and I think Jon's point is 19 valid. For the dispatcher, a call coming in for police 20 services, fire services, EMS services or anything else is 21 just a call. It's a call. 22 MS. DAVIS: Sure. 23 COMMISSIONER WILLIAMS: Doesn't take a man or 24 woman any more time to dispatch an ambulance as it does to 25 dispatch a police car. 7-13-05 jwk 46 1 MS. DAVIS: That's exactly right. But if we 2 did not have this ambulance service, what I'm saying is, 3 then the six dispatchers or however many we have in the P.D. 4 could be reduced by the equivalent of two persons. 5 COMMISSIONER LETZ: No. 6 JUDGE TINLEY: Let me get to the broader 7 question. I think we would all agree that -- that the 8 utopian answer would be that the user or the utilizer pay 9 for the service. That's -- that's where we'd all like to 10 get. 11 MS. DAVIS: Sure. 12 JUDGE TINLEY: From a user standpoint, we've 13 got two different figures. One is slightly under 14 70 percent; one's slightly over. That would seem to be a 15 pertinent benchmark, because, based upon the revenue 16 generated, and presumably the disallowables and the losses 17 incurred, probably running the same proportion, we don't 18 have anything to indicate otherwise. Now, granted, when you 19 go on these longer runs out in the county, there are 20 additional mileage charges imposed, and maybe some 21 adjustment should be made in connection with that portion of 22 the service utilization to provide that. Because of these 23 longer runs, maybe a -- a larger percentage of that should 24 be paid by the County. 25 But when it comes to actual utilization, 7-13-05 jwk 47 1 we're looking at approximately 70 percent -- maybe slightly 2 more, based upon the more current call figures -- that are 3 actually for city residents, and that's the utilizations 4 that's user-pay that we're trying to look to. So, I think 5 we've got to use both figures rather than just try and throw 6 them all in one big hat and -- and say, "Well, we can't 7 really figure this out, so we'll just slice it down the 8 middle," or slice it some way or the other. I think we've 9 got to figure what user -- what the user aspects are in the 10 city and the county. And the base -- the base charges are 11 apparently -- the vast majority are generated by -- by 12 in-county -- I mean in-city service. And I suspect that the 13 additional mileage charges that are imposed are out in the 14 county, and we need to take a look at that. 15 COMMISSIONER WILLIAMS: I think that same -- 16 I think that same argument the Judge is putting out applies 17 to disallowables. You know, if we -- disallowables, by your 18 own system utilization, are -- are 26 percent of those 19 attributed to calls out in the county, then certainly the 20 County has responsibility for that piece. 21 MR. WAMPLER: Well, first of all, I mean, I 22 don't want to have it mischaracterized that somehow we threw 23 a dart at this and came up with 50 percent. I'm not saying 24 that it's not valid to look at number of runs, but 25 effectively, as Don said, the number of runs are irrelevant. 7-13-05 jwk 48 1 I mean, if they're all half-mile runs spread across the 2 county and the city, the fact is, we're looking at the use 3 of the resource, which the is the equipment and the 4 manpower, and it's the time in the vehicle, the time on the 5 road, and the mileage. And that's not an arbitrary number; 6 it's about fifty-fifty, and so that's why we came up with 7 that. 8 JUDGE TINLEY: It may well be that you need 9 to increase that additional mileage charge. 10 MR. WAMPLER: So -- 11 JUDGE TINLEY: If you've got an inordinate 12 amount of labor costs allocable to additional mileage 13 charges, maybe you need to increase that. 14 MS. DAVIS: Well, I think -- 15 JUDGE TINLEY: That may be something you need 16 to look at. 17 MR. DAVIS: The fallacy, in my mind, of that 18 sort of breakdown, Judge, is that you've got costs 19 associated with providing that service; that's what I'm 20 going to call a standby cost. In other words, whether it's 21 a fixed cost, whatever, but if we don't receive a call, 22 you've still got a certain amount of those costs. And you 23 can't -- you know, that -- by trying to put on it a mileage 24 basis does not account for the costs that you have if you're 25 in the station. You're just -- 7-13-05 jwk 49 1 COMMISSIONER WILLIAMS: We have the same type 2 of formula for fire, and -- and we certainly pay our -- what 3 we believe to be our fair share in terms of fire responses. 4 You have fixed costs, both for manpower and equipment, and 5 they're there and they're standing by. Then they may get 6 one call in the county today, they may get five tomorrow and 7 none the next day, but the costs are there, the equipment's 8 there, and we pay our piece of that. I don't know why that 9 -- I shouldn't say I don't know why. I'm questioning 10 whether or not the same rationale or formula has been 11 applied in this case. 12 MR. WAMPLER: That may not always be the 13 case. I'm not saying we've looked at that, but I'm saying 14 that the status-quo that -- the situation we're currently in 15 has been in place for many years, longer than anybody at 16 this table's been in their current position, and 17 circumstances beyond our control have changed, and we're 18 trying to find an equitable way to solve that issue. Your 19 example may be entirely correct, but I think it's not safe 20 to say that that's always going to be that way. We do have 21 those fixed costs for the staffing and equipment. We have 22 dedicated ambulances that are, you know, serving the 23 population that we have to pay for. And instead of asking 24 the County to pay 10 percent, 20 percent, whatever it is of 25 the entire budget, we're trying to show that our actual 7-13-05 jwk 50 1 time, fixed costs, contingency fund, what-have-you, is built 2 into having that service available to all the citizens of 3 the county, and we're upside down $375,000. We need to 4 bridge that gap. That's the bottom line. And we can show 5 that time in the ambulance and mileage is about fifty-fifty. 6 COMMISSIONER LETZ: I understand that, but I 7 just -- I can't get over -- I guess, let me go back to 8 another question. Y'all -- as I understand it, there's two 9 ambulances pretty much on call all the time in Kerrville, so 10 what you're telling me is that if the County doesn't pay 11 50 percent, you're going to one ambulance? 12 MR. WAMPLER: No. What I'm saying is that if 13 -- if we did -- let's put it another way. If we didn't have 14 to run into the county 50 -- 50 percent of our mileage, the 15 wear and tear on our vehicles would not be as great as it 16 is, okay? 17 COMMISSIONER LETZ: And I agree. 18 MR. WAMPLER: And the replacement costs and 19 the replacement cycle of those vehicles would not be as 20 great. 21 COMMISSIONER LETZ: I agree. 22 MR. WAMPLER: So the overall cost over time 23 would be diminished by some factor. 24 COMMISSIONER LETZ: Well, see, but -- no. I 25 agree with the vehicle part of it; there's an excessive cost 7-13-05 jwk 51 1 or more of a surcharge to go to the County. But all of your 2 manpower and everything else, your infrastructure, 3 administration, all that is not going to change whether the 4 County's around or not. I mean, you're going to keep -- I 5 cannot imagine that Kerrville's going to go to one ambulance 6 if the County -- if the County didn't exist. Because the 7 population -- 'cause there's no -- I mean, I don't think 8 they physically could handle over 70 percent of the calls 9 that they're currently getting with one ambulance, so I 10 think that there's a -- 11 MR. DAVIS: Well, I disagree with you, 12 Jonathan. I think there will be -- if we cannot agree on a 13 contract here and the City stops providing service in the 14 county, I think there will be adjustments in the operating 15 department. 16 COMMISSIONER LETZ: I think adjustments, but 17 I don't think it will be a 50 percent reduction. 18 MS. DAVIS: I don't know what that number is. 19 MR. WAMPLER: We're not asking for 50 percent 20 participation in the whole budget, so we're not comparing 21 apples to apples. There would be a reduction that would be, 22 I think, easily commensurate with the amount that we're 23 asking for the County to help us with on the down -- on the 24 down side. I mean, that could be two -- two and a half 25 people. 7-13-05 jwk 52 1 COMMISSIONER WILLIAMS: Might be. But just 2 go back -- I'm hung up on the 26 percent stat and the 3 disallowables. A disallowable is a disallowable, whether 4 it's a city call or a county call, and the only percentage 5 -- only stat that resonates with me is -- is the 26 -- 6 26 percent of the whole. 7 MR. WAMPLER: Mm-hmm. 8 COMMISSIONER WILLIAMS: Of disallowables. 9 Anything above that, to me, is an inflated -- is disparity, 10 let's put it that way. If the -- you know, it seems to me 11 it breaks -- the pie breaks up that way. A disallowable is 12 a disallowable no matter how far a way it is or how close it 13 is, how long it took or how long it didn't take. 14 COMMISSIONER NICHOLSON: We wouldn't have to 15 have this discussion if we agreed that it ought to be a 16 strategy of user-pay. 17 JUDGE TINLEY: User-pay. 18 MR. WAMPLER: Right. 19 COMMISSIONER LETZ: The -- and another note, 20 though, I think that the -- this is made based on 2003-2004. 21 Certainly, even if we were -- if I was to agree to go with 22 these numbers, there'd be adjustments for eastern Kerr 23 County and western Kerr County going to different services, 24 which are the longest runs and are going to increase your 25 run times, percentage-wise, probably pretty substantially. 7-13-05 jwk 53 1 There's not that many calls that go into those areas, but 2 they are, by far, the longest, just 'cause it's -- you're 3 talking about, minimum, hour and a half, if they don't spend 4 any time there. And -- I mean, and in our -- they don't -- 5 everyone over here may not know yet, but in the budget, I'm 6 going to ask that we subsidize Kendall County, give them 7 some money to do this. I mean, I'm not -- we can't -- 8 there's no way we can just ask them to send an ambulance up 9 into Kerr County for nothing. So I think -- I mean, 10 clearly, we have to -- that has to be looked at, as well as 11 look into the fact that there's -- the extreme long-distance 12 runs are being taken out. 13 MR. WAMPLER: Well, I think, again, one of 14 the issues is the fact that we haven't looked at this in 15 this detail in a long time, and this is a one-year contract. 16 And there are a lot of issues here, like the impact of 17 Kendall County serving and like the impact of Kimble County 18 serving the west part of the county that we can't quantify 19 yet. And I think, to the extent that we can look at those 20 on an annual basis and come to some understanding about how 21 we're going to split the burden will be useful in the next 22 several years. But I don't -- we can't answer those 23 question right now. 24 COMMISSIONER LETZ: Well, I guess -- you 25 know, again, I said probably 15 minutes ago I think we're 7-13-05 jwk 54 1 done today. 'Cause it seems that we have a view and you 2 have a view, and -- 3 MR. WAMPLER: What I was going to say, 4 Jonathan, we've looked at this -- and I'm not saying that 5 there's not some room here somewhere, but rather than us 6 going back and coming back with another proposal, we'd like 7 to -- I mean, I'm hearing from Bill that there's some 8 disparity with regard to disallowables on county patients 9 versus city patients, and I'm hearing from the Judge there's 10 -- there ought to be some whittle room on mileage and 11 surcharge for mileage beyond a certain amount. I'm hearing 12 from you a slightly different issue. So, I mean, I -- I 13 want to hear from you guys, rather than us coming back with 14 another proposal. Because, I mean, there's not any 15 agreement amongst yourselves. 16 COMMISSIONER LETZ: I think there's agreement 17 that the -- 18 MR. WAMPLER: No, I understand, but there's 19 not any agreement in terms -- from what I'm hearing today, 20 in terms of methodology. 21 COMMISSIONER LETZ: You want us to give a 22 counterproposal, so to speak? 23 MR. WAMPLER: Sure. This is our proposal. I 24 don't think we need to come back with another one. 25 COMMISSIONER BALDWIN: I agree. 7-13-05 jwk 55 1 JUDGE TINLEY: Certainly. 2 COMMISSIONER LETZ: I agree. 3 COMMISSIONER WILLIAMS: We can do that. 4 JUDGE TINLEY: That's a proper request. 5 COMMISSIONER BALDWIN: And I hope that -- one 6 of my ideas -- one of my thoughts is -- is going back to the 7 way my granddaddy or our granddaddies would do this thing, 8 and consider -- just consider using the old barter system. 9 Can we trade our animal -- part of our animal program for 10 part of the ambulance program? Can we do your collection? 11 We have a Collections Department here that can be very 12 aggressive. Very aggressive. And, you know, can we look at 13 some of those kinds of things and do a little trade-off? I 14 think it's worth thinking about, at least. 15 COMMISSIONER LETZ: I agree. And I guess the 16 final point -- and I didn't bring it up, because I'm not 17 sure -- I hate asking questions when I don't have any vague 18 idea what the answer is. Indigent calls. What -- do you 19 have any idea what percent of these goes to indigents? 20 MS. DAVIS: No, sir. 21 COMMISSIONER LETZ: And the reason I bring it 22 up is 'cause the County pays 100 percent of that. I mean, 23 we're paying -- and I don't want to -- I mean, I don't think 24 it's a fair thing for -- when we have a homeless person who 25 goes in an ambulance, okay, we're going to pay the ambulance 7-13-05 jwk 56 1 cost to get him to the ambulance, because it comes out of 2 our indigent funds. You know, the hospital, we pay over 3 there -- or provider, and then we have to pay it again. 4 MR. WAMPLER: We can't qualify -- 5 COMMISSIONER LETZ: I don't know how -- if 6 you -- I don't know how you get into that. But, unless my 7 mind isn't working right, on any indigent call anywhere in 8 the county, we're already paying for that. And that's -- 9 it's not y'all's fault; it's state law. The law says that 10 we -- County's responsible for it, so we pay it. 11 COMMISSIONER WILLIAMS: Up to 80 percent. 12 COMMISSIONER LETZ: That's about $800,000 a 13 year for us. Not -- I mean, total indigent. 14 MR. WAMPLER: I don't know for sure, but I 15 would think that indigents would be Medicaid-eligible, and 16 if they're beyond a certain age, they'd be Medicare-eligible 17 for reimbursement on EMS service. 18 COMMISSIONER LETZ: I don't know. 19 MR. WAMPLER: So, you know, of course, we 20 can't qualify that before we make the run, and then if they 21 don't pay us -- 22 MR. DAVIS: I'm sitting here thinking; we'll 23 ask for a financial statement while he's lying there. 24 (Laughter.) 25 MR. WAMPLER: We don't split that out. 7-13-05 jwk 57 1 COMMISSIONER WILLIAMS: Guy living under the 2 bridge, "Give me your financial statement." 3 COMMISSIONER NICHOLSON: I was thinking out 4 there on 1340, while I'm bleeding, I'm going to call and 5 say, "How much do you charge to send an ambulance?" No. 6 COMMISSIONER BALDWIN: Yeah. 7 (Discussion off the record.) 8 COMMISSIONER BALDWIN: Thank you guys very 9 much. 10 MR. DAVIS: You bet. 11 COMMISSIONER WILLIAMS: Good discussion. 12 COMMISSIONER BALDWIN: I think we had a good 13 discussion, and may not agree on everything, but at least we 14 had a good discussion. We will -- we will come to some 15 agreement before it's over with, though. 16 COMMISSIONER NICHOLSON: Don, do you know if 17 any governments that provide EMS do not agree to accept 18 Medicare payments? 19 MS. DAVIS: I do not. Now, there may be, 20 Dave, but I'm not familiar -- none of the cities in which 21 I've worked had that policy. 22 COMMISSIONER NICHOLSON: Do you think it's 23 allowable? Can it happen? 24 MS. DAVIS: Oh, yeah, I'm sure. 25 COMMISSIONER LETZ: How would you do that, 7-13-05 jwk 58 1 though? How would you -- when the 9-1-1 call comes in, 2 dispatcher says, "Do you have -- are you on Medicare?" I 3 mean, we just -- you don't allow, I mean -- 4 COMMISSIONER NICHOLSON: You don't make a 5 deal with Medicare to do it, so -- 6 MR. WAMPLER: You just don't tell them, but 7 you just -- you send them a bill, and then you get into a 8 collections issue. I'm not saying it's good or bad, but 9 then you're going to the patients, and if do you that, then 10 you're not allowed to bill the government for the service. 11 COMMISSIONER LETZ: What is your-all's -- 12 what's a per-run cost? Do y'all have that? 13 MR. DAVIS: I haven't figured it. 14 MR. WAMPLER: Raymond knows it. 15 COMMISSIONER NICHOLSON: I took a ride in '99 16 in the same ambulance; it was about $800. And my private 17 insurance company paid most of it, and I got a bill from EMS 18 for the rest of it. 19 MR. WAMPLER: My son had a transfer to San 20 Antonio in '97 -- '98. It was $650. 21 COMMISSIONER NICHOLSON: Probably 50 percent 22 more now. 23 MS. DAVIS: It varies with the treatment we 24 have to give, too. We have a base rate and 6,000 different 25 add-ons. 7-13-05 jwk 59 1 JUDGE TINLEY: Thank you, gentlemen. That'll 2 conclude the meeting. 3 (Joint workshop adjourned at 10:13 a.m.) 4 - - - - - - - - - - 5 6 7 STATE OF TEXAS | 8 COUNTY OF KERR | 9 The above and foregoing is a true and complete 10 transcription of my stenotype notes taken in my capacity as 11 County Clerk of the Commissioners Court of Kerr County, 12 Texas, at the time and place heretofore set forth. 13 DATED at Kerrville, Texas, this 21st day of July, 2005. 14 15 16 JANNETT PIEPER, Kerr County Clerk 17 BY: _________________________________ Kathy Banik, Deputy County Clerk 18 Certified Shorthand Reporter 19 20 21 22 23 24 25 7-13-05 jwk