By Mark Gutglueck
More than four decades after San Bernardino County’s largest ambulance company established a political hammerlock on the region, the San Bernardino County Professional Firefighters Union has taken a step toward inspiring possible reform by calling attention to a monopolistic system that has long endangered public safety.
The firefighters union, known as Local 935, has called for action to remedy shortages in the High Desert’s ambulance transport system.
Over much of San Bernardino County including the High Desert, American Medical Response, known by its acronym AMR, holds a virtual monopoly on the provision of ambulance service. AMR is only the latest ambulance company to come into a position of dominance in San Bernardino County. To get into its enviable position, it applied the same formula of the companies that preceded it.
That formula involves plying the county’s political leaders with hefty campaign donations to encourage them to lock in for the company an operational advantage that essentially limits or eliminates competition.
In the 1960s and before, the emergency medical transportation business was wide open in San Bernardino County. Those seeking to get into the business would merely purchase an ambulance or adapt a vehicle to serve as one, outfit it with a minimal amount of life support equipment, obtain a business license in whatever city or area they chose, inform the local police and fire departments and hospitals of their existence, and acquire a police/fire department radio scanner. They would then respond to the location of accidents, fires or medical emergencies.
As more and more ambulance companies sprouted up, the competition increased. This had, for the public, two salutary impacts: one, it drove down prices; and two, it pretty much ensured adequate coverage to the county’s 20,105 square mile area. It had, for the ambulance operations, two negative impacts; one, it limited profitability; and two, it resulted in haphazard, overlapping, and inefficient dispatch and response practices and protocols in which, for example, a first ambulance stationed on the east side of a city having driven nearly the entire distance across the municipality west to pick up a patient before heading back to a hospital in the center of the city would encounter another ambulance that originated at the west end of the city racing east to load up a patient at an accident or emergency scene very near to the point from which the first ambulance had been dispatched. On occasion, two ambulances would arrive at an emergency situation location almost simultaneously and physical hostility or something near it would break out as the ambulance drivers and their accompanying emergency medical technicians or paramedics would have to joust over who would make the transport to the emergency room.
In the 1970s, Terry Russ, Homer Aerts, Steve Dickmeyer and Don Reed, all of whom operated ambulance companies on the west and central portion of San Bernardino’s Inland Valley and had been competing against one another for years, smoked a peace pipe and resolved to merge their operations into one, consolidating and streamlining their dispatch service and better coordinating it with the local fire and police departments. Through efficiencies and the sharing of resources, they were able to overwhelm the other ambulance operators they were in competition with, lower their prices, and induce most of those competitors to either go out of business, merge with them or sell out to them. Functioning under the name Mercy Ambulance, Russ, Aerts, Dickmeyer and Reed pooled their money and began making substantial political contributions to local politicians at both the city and county level. They then used this newfound political clout and influence to have both the county board of supervisors and various city councils “regulate” the ambulance industry, which included essentially adopting the vehicle, equipment and employee training standards Mercy had in place as the minimum requisites for an ambulance operation within their jurisdictions. The politicians were able to do so by asserting that this enhanced public safety.
As Mercy solidified and expanded its domination of the local ambulance industry and it grew to become preeminent among the county’s campaign donors, the county and many of its cities moved to create franchises in which a single ambulance company was allowed to operate and from which any other companies were prohibited from operating. Not surprisingly, in San Bernardino County Mercy was granted the lion’s share of these exclusive franchises.
When protests were registered, politicians were ready with the talking points provided to them by Mercy Ambulance, its lawyers or lobbyists, which held that ambulance service is such an important and crucial function, literally a matter of life and death, that the personnel and equipment utilized in the provision of the service had to be top notch. Because of the expense of ensuring this level of quality, the ambulance companies could not be put into a circumstance in which they had to compete because doing so would so reduce the ambulance companies’ profitability, such that they would be forced to either cut corners on the quality of service they offered or go out of business, which in either case would be contrary to public safety. In this way, monopolies in the realm of ambulance service generally, and in the case of Mercy Ambulance specifically, were justified and perpetuated.
In 1984, a brief-lived scandal relating to Mercy Ambulance’s trend toward the domination of its industry occurred when, in Rancho Cucamonga, which had at that point resisted the push for the creation of an ambulance franchise within its 49-square mile confines, submitted to an overture that originated with then-Second District San Bernardino County Supervisor Cal McElwain to have the city regulate its ambulance service. Mercy Ambulance was a major campaign donor to McElwain, as it was to two of his political allies on the Rancho Cucamonga City Council, Dick Dahl and Chuck Buquet. Dahl and Buquet moved for the city to adopt such an ordinance regulating ambulance service and the full council accommodated that request, directing city attorney Robert Dougherty to draft the ordinance. Upon Dougherty’s preparation of the ambulance regulation ordinance and its presentation to the council, it was voted upon and was given a 5 to 0 vote of passage, and needed only a second reading, or vote, by the council to become law. In the two week interim before the next council meeting, however, it was publicly revealed that Dougherty’s law firm represented Mercy Ambulance and that the standards outlined in the ordinance matched precisely the equipment used by Mercy Ambulance and the certification levels achieved by Mercy Ambulance’s employees. This revelation led three of the council’s members, including then-mayor Jon Mikels, to conclude that the ordinance had been intended to further perpetuate Mercy Ambulance’s crushing hold on the ambulance industry. The trio opposed it at the second reading, with only Dahl and Buquet supporting it. The ordinance failed to pass and the ensuing controversy resulted in the council terminating Dougherty as city attorney. Mikels latched onto the issue as one of a series of pay-to-play scandals dogging McElwain he used in successfully challenging McElwain in the following year’s election for Second District supervisor.
While the failure of the Rancho Cucamonga ambulance regulation ordinance was a minor setback for Mercy Ambulance, the implications of that scandal proved more serious for McElwain and Dougherty than the company, which overcame that minor bump in the road and remained the largest ambulance operator in Southern California outside of Los Angeles County. Its expansion included the creation of Mercy Air Ambulance in 1989, utilizing medical transport helicopters flying from Rialto Municipal Airport.
In 1995, the company sold its helicopter ambulance division to Air Methods, Corp., a Colorado-based company, at tremendous profit on its investment. Air Methods adopted the formula used by Russ, Aerts, Dickmeyer and Reed of providing local politicians with hefty campaign contributions, maintaining the company’s monopoly. As Russ, Aerts, Dickmeyer and Reed reached retirement age, they faded into the sunset. Consequently, their corporate successors did not continue to use the same methodology they had, and the reserve of political capital and goodwill Mercy ambulance had accumulated dissipated. Other companies leapt into the breach. In this way, Mercy Air Ambulance, owned by Air Methods, kept its primacy in the air, with a monopoly on air ambulance service in San Bernardino County. AMR has essentially replaced Mercy as the dominant ground ambulance service provider. Like Mercy before it, it has utilized heavy political donations to establish its position of dominance.
In 2005, the San Bernardino County Grand Jury issued a report stating that campaign contributions by Mercy Air were a factor in the San Bernardino County Board of Supervisors having consistently made decisions to keep Mercy Air as the sole air ambulance provider authorized to operate in the county. Both the company and county officials denied that was the case.
For close to 15 years, American Medical Response, or AMR, has enjoyed, if not an absolute monopoly, domination of the San Bernardino County ambulance market. That status has been conferred on it by both the San Bernardino County Board of Supervisors, individual city councils throughout the county and ICEMA, the Inland Counties Emergency Medical Agency. ICEMA oversees emergency service provision issues in San Bernardino, Mono and Inyo counties. Its governing board consists of the five members of the San Bernardino County Board of Supervisors.
Earlier this month, the San Bernardino County Professional Firefighters Union, or Local 935, using social media posts indicated there is a problem with ambulance response times in the desert. What was suggested is that AMR has spread and dispersed its resources throughout the county, such that on certain occasions when there has been a glut of accidents or emergencies in the High Desert, there are not enough units to handle all of the calls. Such a circumstance, in public safety agency jargon, is referred to as “Level Zero.”
According to one of the posts, “The issue of Level Zero is a growing problem and AMR is consistently not staffing enough ambulances for the areas they are responsible for. This has been a problem for several months in the High Desert.”
Because the county board of supervisors and ICEMA have in essence conferred a monopoly on AMR in the desert, no private sector ambulances are immediately available to respond to incidents in the High Desert. For the most part, but not always, paramedic units from city, county or state fire agencies are available to respond, but on occasion, there have been substantial delays in ambulance response when the nearest governmental agency paramedic units were on a call elsewhere and the closest AMR units were located as far away as San Bernardino or Redlands, at least 35 minutes driving time away. On other occasions, county or city units have responded in a timely manner, but that has resulted in those units being tied up at that scene, leaving other areas of that agency’s responsibility uncovered, and in some cases resulting in treatment or response delays there.
Moreover, the government agency firefighters that respond in place of an AMR unit must remain engaged there until a tardily arriving AMR vehicle shows up. This can delay the response of those firefighters to other emergencies, medically related, fire related, or otherwise.
A posting the union provided included a dispatch audio recording from New Year’s Eve in which two pedestrians were struck by a vehicle on Mojave Drive. Clearly audible in the recording is one and then a second firefighter requesting ambulances at the scene. They are informed that no units are available in the High Desert and that a unit from San Bernardino will respond. As it turned out, the ambulance from San Bernardino was recalled after an AMR unit in the area was freed up and was able to speed to the Mojave Drive location.
On other occasions, the union claims, no such nearby relief arrived on a timely basis, and ambulances from San Bernardino, Colton and Redlands had to make the trip to Victorville, Hesperia or other locations on or off the 15 Freeway.
“When ambulances are dispatched to 911 calls in the High Desert from as far away as 40 miles in San Bernardino, we believe there is a problem that needs to be addressed,” one of the union posts states.
An issue, according to the union, is that AMR does not disclose to the local fire departments, either ahead of time or in real time, how many of its ambulances are assigned to a given area. On average, a “Level Zero” incident occurs in the High Desert daily, firefighters reported.
Under the contract the county has with American Medical Response, the company is supposed to respond to 90 percent of emergency calls within 9 minutes and 59 seconds in all but the most remote ends of the county. If the company does not meet that standard, it is supposed to be subject to fines by the county. Some firefighters have suggested the company has failed to meet that standard and the county has not disclosed whether any of the monetary penalties against the AMR have been triggered.
The firefighters said the ball is in ICEMA’s court to take corrective action. That the political leadership of ICEMA – the board of supervisors – individually and collectively are recipients of substantial contributions from AMR leaves the institution’s staff reluctant to engage in any disciplinary action against the company.
By Mark Gutglueck