In an historic shift, the San Bernardino County Board of Supervisors on Tuesday voted to confer the county’s ambulance service franchise on a consortium of 15 public fire agencies and departments, ending the 40-year arrangement it had with American Medical Response, a private corporation.
The implication of the change is multi-fold.
While perhaps not a death knell for the for-profit ambulance service providers that once dominated the county, the change likely means the presence of corporate ambulances will diminish. Prior to the 1970s, few fire departments in San Bernardino County hired personnel who were firefighters first and foremost and, in most cases, exclusively. Only rarely were firemen in the Inland Empire at that time certified or licensed as emergency medical technicians or paramedics, though an effort was made to give them basic first medical response skills, such as artificial respiration and resuscitation.
Medical-related transport companies, ones that engaged in both emergency and non-emergency service, worked in tandem with both law enforcement agencies and fire departments in responding to circumstances of grave injury, heart attacks and the like. In the distant past, there was only limited standardization in the ambulance industry. As the 20th Century progressed, so too did the sophistication and equipment aboard ambulances and used by drivers and attendants, whose training and skill levels likewise advanced.
While non-emergency medical transport – consisting generally of driving elderly patents from their residences to doctor’s offices for scheduled examinations or medical treatments – did not require much more than a conscientious driver and a car or van, emergency medical transport – involving a driver/emergency medical technician and an accompanying paramedic using an ambulance outfitted with sophisticated live-saving and life-sustaining equipment – represented a substantial investment and ongoing expense. Only those willing to make such investments and commitments got into the business. Once they did, the competition was cutthroat, as each ambulance operator had to compete against other ambulance operators for business. That competition, in which the first ambulance to arrive on the scene got the job and therefore the ambulance fee, had a salutary effect, ensuring faster response times, which can be crucial in an emergency medical situation.
By the mid-1970s, Terry Russ, Homer Aerts, Steve Dickmeyer and Don Reed had clawed their separate ways to the top of the emergency medical transport heap on the west and central portion of San Bernardino’s Inland Valley after competing against one another for years and choking out others with less staying power. At that point, they 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 their company, which was dubbed Mercy Ambulance. After pooling their money and initiating a program of making substantial political contributions to local politicians at both the city and county level, Russ, Aerts, Dickmeyer and Reed 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, not to mention the most lucrative ones.
As Mercy grew, so did the scope of its operations and its power. The company added helicopters to its line of service and extended its reach all over 20,105 square mile San Bernardino County – a land area the size of four New England states.
A new kid on the block who persisted in the ambulance business in San Bernardino County despite the domination of Mercy Ambulance was American Medical Response, a company which came into the region from elsewhere while Mercy was still thriving in the heart of San Bernardino County. At first, American Medical Response limited itself to servicing the wide open expanse of the Mojave Desert, a place Mercy was willing to let the company operate, given that the calls were sporadic, drives were long and the profits marginal. In 1981, American Medical Response, or AMR for short, was given the county franchise pertaining to unincorporated areas of the county, that is, those places other than where there were established cities. The lion’s share of that unincorporated area was the desert, where AMR had by that point set up an overwhelming presence.
As Russ, Aerts, Dickmeyer and Reed aged and grew wealthier, they began, slowly at first, to disengage from and then inevitably pulled out of the stressful emergency response business entirely. A first step in that direction was selling off – at considerable profit – the Mercy Air wing. Thereafter, they sold or let their heirs take on the ground ambulance fiefdom that Mercy represented, and they withdrew into a retirement of luxury and comfort. With each stage of Russ’s, Aerts’, Dickmeyer’s and Reed’s detachment from the ambulance business, American Medical Response moved in to fill the vacuum created by Mercy’s exodus. Simultaneously, AMR took a leaf out of Mercy Ambulance’s playbook, and it too made hefty political contributions.
Over time, ICEMA – the Inland Counties Emergency Medical Agency – which oversees emergency service provision issues in San Bernardino, Mono and Inyo counties, would confer upon American Medical Response favored status in San Bernardino County that would rival that of Mercy Ambulance a generation before. Because it was ICEMA rather than the board of supervisors that drove the move to grant AMR its position at the top of the ambulance service heap, it at first glance appeared that AMR had achieved that favored status straightforwardly and without the interference of political influence or favoritism. The reality, however, is that ICEMA’s governing board consists of the five members of the San Bernardino County Board of Supervisors, each of whom is entrusted with looking after issues pertaining to emergency medical response not just within the expanse of San Bernardino County but in 10,227-square mile Inyo County and 3,132-square mile Mono County. So, by making contributions to the supervisors, AMR, over the years, was able to keep its nest feathered.
That feathering consists of what are referred to as exclusive operating zones. Thus, there are extensive areas in San Bernardino County, Inyo County and Mono County where one ambulance company has not only primacy but a virtual monopoly in that it, and only it, is authorized and licensed to function there under normal circumstances. The ostensible rationale for granting these monopolies is that operating ambulances is an expensive proposition, not to mention one that is crucial to public health and safety. Competition between ambulance companies has the potential, so the reasoning goes, of driving down the prices those companies charge to the point that their operations will not be profitable enough for them to remain in business. Upon these ambulance companies going out of business, the public would be put into a position where there would be insufficient emergency medical transportation service available to ensure public safety. Thus those arrangements – the exclusive operating zones – have been established.
Some have long disputed that the exclusive operating zones are necessary, and they assert they are rather a ploy by which county politicians have further inculcated a pay-to-play ethos into the county’s governmental function. Among those critics of exclusive operating zones are some who maintain the monopolistic system has long endangered public safety. One of those was the county’s firefighters’ union, known as Local 935, which a decade ago suggested the exclusive operating approach has on occasion created critical shortages in the High Desert’s ambulance transport system.
For years, the county’s decision-makers ignored those warnings.
The overall situation with regard to emergency medical care in the field and emergency medical transport, however, has been gradually evolving. Beginning gradually in the 1970s with the more financially enabled jurisdictions in San Bernardino County and in parallel with evolving standards in the firefighting industry generally, fire departments have striven toward training their existing personnel with regard to lifesaving skills and rudimentary medical care, such that over the years fire departments, one by one could become more selective in their hiring practices. In this way, those competing for the limited number of plum firefighting positions had to find a way to distinguish themselves. This commonly involved those aspiring to becoming firemen or firewoman enrolling in a junior college or community college immediately out of high school and obtaining either a two-year fire science degree or two-year degree in the field or nursing or otherwise obtaining licensing as an emergency medical technician or paramedic.
In this way, the near monopoly that the private sector, for-profit ambulance companies had on certified/licensed paramedics in San Bernardino County in the 1980s has come to an end. This has been paralleled by fire departments acquiring as standard equipment field medical service vehicles outfitted with advanced state-of-the-science medical equipment rivaling or indeed surpassing that available to private sector ambulance companies.
A final crucial factor is that at the local level in San Bernardino County prior to the 1990s, mega-donating to politicians had been the exclusive province of the private sector, primarily the development industry and companies such as Mercy and AMR who had a dog in the hunt when it came to governmental contracts or franchises. Beginning first with the Safety Employees Benefit Association under its then-President Chris Smith thirty years ago, governmental employees unions increased their dues to create a pool of money then used either directly by those unions or political action committees they formed to make monetary donations to politicians, primarily incumbent office holders at the county and city levels, to convince them to increase employee wages and benefits. Over the course of three decades, this practice has matured into the various governmental employees’ unions, including the firefighters’ union, applying money to influence policy decisions that might impact how governmental agencies’ money is spent, including whether certain tasks are to be privatized and performed by entities outside government, such as companies under contract or with franchises, or kept in-house.
Whereas in previous years, the AMR contract was merely “rolled over” in what the county referred to as “a grandfathered process,” last year county officials began to look forward toward what action it would take with regard to the expiration or continuation of the contract. On December 20, 2022, the county released a request for proposals – a solicitation of bids – inviting prospective providers to provide ground ambulance service in 11 of the county’s 26 exclusive operating areas.
Responding to the request were AMR and Consolidated Fire Agencies, known by its acronym CONFIRE, a joint powers authority which provides communications, dispatch, computer information systems support, and geographic location information to its nine member agencies – the Apple Valley Fire Protection District, Chino Valley Independent Fire District, the Colton Fire Department, the Loma Linda Fire Department, the Rancho Cucamonga Fire Department, the Redlands Fire Department, the Rialto Fire Department, the San Bernardino County Fire District and the Victorville Fire Department – and four contract agencies – the Big Bear Fire Department, the Montclair Fire Department, the Running Springs Fire District and the San Manuel Fire Department.
AMR featured in its response that it could commit 12,889 weekly unit hours to respond to calls, had 111 ambulances available during peak system demand and stationed throughout the service area backed with 39 additional available ambulances available to meet surges. It emphasized that it was the current provider of the services with vehicle infrastructure in place and 10 managers and 18 field supervisors and a medical director familiar with the comprehensive needs of the service area. The company offered rates of $3,958 for both basic life support and advanced life support, $2,834 to carry out an interfacility transport, and $4,392 for critical care transport.
In its response, CONFIRE said it could devote 10,371 weekly unit hours to respond to calls, had 93 ambulances available at peak demand, with 45 additional ambulances available to meet surges throughout the service area, would subcontract with Priority Ambulance, which also serves Maricopa County in Arizona, that it will establish ambulance staging locations, on-board personnel, and acquire vehicles upon receiving the contract and that it has leadership and management to meet the demands of providing the service, including nine managers and 18 operations supervisors as well as a medical director and that it controls the regional emergency services communication system. Its proposed rates for its advance life support service were $3,547 for non-emergency and interfacility transfer, $4,053 for emergency transport, $2,533 for non-emergency basic life transport and $3,167 for emergency basic life transport and CCT $5,067 for critical care transport.
What the county referred to as an “independent review panel” made up of four evaluators individually scored each proposal on 14 key areas – system requirements, response time standards, clinical performance, deployment plans, vehicles, medical supplies and equipment, personnel, hospital and community requirements, disaster preparedness/response, quality management, electronic patient care reports, centralized emergency medical dispatch center, financial and administrative requirements qualifications, and future system enhancements – for the purpose of making a recommendation to the county for final negotiation of contract terms. The total cumulative scores, against a standard with 1,720 points maximum, favored AMR, which registered 1,519 total points against 1,515 points for CONFIRE. The county emphasized that the score differential was a mere quarter of 1 percent, with one of the evaluators favoring AMR by 35 points, 419 to 384, while the other three evaluators found in favor of CONFIRE by scores of 383 to 373, 363 to 346 and 385 to 381.
Based on the negligible difference between the scores, the county provided AMR and CONFIRE, with notice to enter into contract negotiations with the county and that the final contract approval rested with the board of supervisors.
After those negotiations concluded, the county purchasing division on October 27, 2023, emailed AMR a notice of intent to recommend that it be awarded a contract extension from the time its current contract expires on March 31 from April 1, 2024 through September 30, 2024 to allow CONFIRE to get prepared to take on the contract for an initial term from October 1, 2024 through September 30, 2029.
AMR lodged a protest, alleging the county had failed to follow the selection procedures and adhere to requirements specified in the request for proposal, awarding the contract to the entity which had prevailed in the competition and that it had otherwise violated state and/or federal law. The county’s purchasing agent, Ariel Gill, who reviewed and considered the protest and notified AMR of its decision to deny the protest.
Thereafter, a motion by Supervisor Jesse Armendarez seconded by Supervisor Curt Hagman to deny the protest from American Medical Response and schedule a vote to consider awarding the contract to Consolidated Fire Agencies and its private subcontractor Priority Ambulance passed by a unanimous vote of the board of supervisors.
At the December 5 meeting, AMR was represented by a spokesman who neglected to identify himself and Mike Rice, the company’s vice president of operations, who made no comments. The unidentified spokesperson said AMR offered “stability, performance and clinical excellence. AMR is in the best position to take this into the future. We’re fully integrated with the fire departments, public health, behavioral health, the communities we serve.” He said AMR had a “depth of resources, history of performance, experience and expertise, disaster response capability and represented a lower risk of liability to the cities and county than have public agencies providing ambulance service. He said that “AMR meets or exceeds all response [time] standards” and featured as part of its vehicle fleet “all-wheel-drive units in key areas that need that… and a disaster command vehicle.” He said the company had helicopter ambulances and was “financially strong” with an established sustainable model.”
CONFIRE was represented by Rancho Cucamonga City Councilfwoman Lynn Kennedy, the chairwoman of the CONFIRE Board of Directors, Rancho Cucamonga Fire Chief Mike McCliman and CONFIRE Chief Nathan Cook. Lynne Kennedy said what CONFIRE was offering something that “will result in increased resources, decreased response times and a delivery model that includes private/public partnership, a private partnership with Priority Ambulance that has the capacity to serve our county and the public partnership that crosses the continuum of care, making sure that every single resident receives the right care at the right time on time every time without exception. It is going to be transformational in three areas. It is going to improve our service delivery, establish an efficient system and invest both financial and human resources back into the system.”
McCliman said that in refining its proposal, CONFIRE “reached out to our elected officials throughout the county. We reached out to our labor unions. We met with every hospital in the county, whether their CEO, vice presidents, their head of nursing or their emergency room doctors.” McCliman said it entered into a public/private arrangement with Priority Ambulance.
Cook said that AMR, as “the incumbent provider cannot perform due to local control and state statutes,” which he enumerated as “four distinctive issues we feel are plaguing the ambulance system in this county, that being a rising and unsustainable call volume, geographical challenges, the frupid [sic] issues in our local hospitals and a bifurcated system between our public and private emergency medical service providers. CONFIRE has hundreds of resources strategically located throughout the entire county. Once we finally bring all the ambulance resources together on the same platform, we’ll be able to leverage all of our emergency medical services resources collectively through a tiered response model, significantly reducing the redundant and parallel responses. This will allow us to hold back ambulances they are truly needed on. As the operational area coordinator for the county, CONFIRE has never known the total number of private ambulances in our system at any given time. We have always been told that information in proprietary. As you know, as a governmental agency we are mandated to be transparent to the communities we serve and nothing is proprietary, especially the health and wellbeing of the public we serve.”
A major portion of audience in attendance was divided between those supporting CONFIRE and those supporting AMR. During the public input portion of the meeting, either side gravitated to one of the two public speaking podiums in the board chamber, with CONFIRE advocates, mostly firefighters, forming a backdrop at one and those backing AMR, predominantly AMR employees or their family members, at the other. With little or no exception, those backing CONFIRE were public employees or elected officials and those supporting AMR were AMR employees or individuals from the private sector.
Rancho Cucamonga Mayor Lloyd Dennis Michael, who was formerly that city’s fire chief, commended the board of supervisors “as you recognize the status quo of how services are being provided needs to be improved and provided in a manner that is transparent, collaborative, efficient and, just as importantly, accountable to our communities and our public. A public/private partnership with Priority Ambulance, CONFIRE’s approach to provide emergency medical care and services is innovative, economically sustainable and will reinvest, most importantly, back into our communities. It is for these reasons that I strongly urge you to select CONFIRE as our new model for the delivery of emergency medical care emergency transport services.
Others supporting CONFIRE were Loma Linda Mayor Phill Dupper, Chino Mayor Eunice Ulloa, Victorville Mayor Debra Jones, San Bernardino Mayor Helen Tran, Victorville City Councilwoman Elizabeth Becerra, Chino Valley Professional Firefighters Association President Pete Roebuck, Victorville City Manager Keith Metzler, Ontario Police Chief Mike Lorenz, San Antonio Regional Hospital President and CEO John Chapman, Rancho Cucamonga Assistant City Manager Elisa Cox speaking on behalf of Rancho Cucamonga City Manager John Gillison, Ontario City Manager Scott Ochoa and Fontana City Manager Matt Ballantyne.
There were a few public employees who fell outside the pattern of governmental workers who supported CONFIRE.
Juana Sotelo, a classified worker with the Fontana School District and member of the United Steelworkers Local 1853, which also represents AMR’s drivers and attendants. “It is is irresponsible to use your seat to vote against renewing the contract with AMR, who has been dedicated to our community for years and provided good, family-sustaining jobs in San Bernardino County. If you go through with this change in violation of our own rules and process, it opens us to liability in the future. You are exposing our community to liability with the first accident that occurs.”
Alex Provenshaw was another exception among public employees, a currently employed firefighter who formerly worked for AMR, who supported maintaining the contract with AMR. He said that many of the firefighter/paramedics working for public agencies formerly worked for AMR and recognized that it had a successful formula for serving San Bernardino County.
A third exception to governmental employees who generally supported CONFIRE was Jorge Gomez, who works for the California Correctional Healthcare System. He said that AMR had performed admirably in transporting inmates to hospitals and to other facilities during the challenges of the COVID-19 pandemic and appeared capable of maintaining a continuum of adequate care during mass emergencies.
Kim Corona, an AMR paramedic, told the board that “AMR has been a longstanding provider here for several years and has done an excellent job in creating job security for those of us who are currently employed. Beyond the interest of AMR employees, Corona said, bringing in Priority Ambulance to serve the community represented a risk to the county’s residents. “We live here. Many of us reside within this county and we are constituents.” She referenced Priority Ambulance as an “out of state third party service which does not know this county, does not know these streets and does not know these communities” that provide “nearly 2,000 less man hours.”
Moreover, Corona said, the county was giving CONFIRE a second bite at the apple after it had lost the competition for the contract carried out with the evaluation process.
“My question to you, board members is this: When did it become acceptable to place proposals side by side in the winner’s ring when one was selected over the other?” she asked. “I urge you to make the right decision.”
Five other AMR employees and five others enunciated support of AMR.
Board of Supervisors Chairwoman Dawn Rowe sought to offer a procedural justification and lay the grounds for a legal defense of conferring the franchise upon CONFIRE despite AMR’s marginal outperformance of its rival in the proposal evaluation.
“The provision in the request for proposals that gives us the board of supervisors, the most discretion in awarding a contract to either entity is stated under the heading in the request for proposals entitled “the contractor scope of work” is summarized as follows: ‘The county realizes that the criteria, other than price, is important, and will award a contract based on the highest scoring proposal that demonstrates the best value and meets needs of the county,” Rowe said. “The language contain in other provisions of the request for proposal discusses the criteria for awarding the contract, which discusses the criteria for awarding the contract, which cannot be ignored by the board. And we can consider which proposal is the best value that meets the needs of the county. Furthermore, we have 2 county policies that I would point to for to consider county policy 1106 and county policy 1104. And I will summarize 1104 as stating that we have an obligation to perform the best value evaluation in the procurement of goods and services. Access to funding creates value. In accordance with Assembly Bill 1705, the Department of Health Care Services developed the public provider ground emergency medical transportation [program] known as PPG EMT. The intergovernmental transfer program, IGT program, [is intended] to provide increased reimbursements to emergency medical transports provided byeligible non contracted public, general emergency medical transportation providers. Of the two proposers that we heard today, Confire JPA [powers authority] may be eligible for this funding, but only Confire JPA. Based on these things, as well as the fact that three of the Four 4 evaluators ranked Confire, JPA, higher than AMR, I would support awarding the contract to Confire JPA.”
The board voted unanimously to support Supervisor Armendarez’s motion, seconded by Supervisor Curt Hagman to deny AMR’s protest and award the five-year contract to CONFIRE.
“We appreciate the service AMR has provided to county residents for many years,” San Bernardino County Chief Operating Officer, who had, together with interim San Bernardino County Emergency Medical Services Administrator Daniel Muñoz overseen for the board of supervisors the evaluation of the two proposals, said in a press release put out after the meeting. “This was a very difficult decision for the board. We are looking forward to a smooth transition and providing the best level of service to those who rely on us in the community.”
AMR expressed consternation with the supervisors’ action in its own press release, which came out only minutes after the county release.
“AMR submitted a superior proposal that was awarded more points than any other proposal, while providing significantly more system ambulances per day to the residents of San Bernardino [County],” according to the company said in its release.
Mike Rice, AMR’s vice president of operations who had remained silent during the company’s presentation during Tuesday’s meeting while allowing its anonymous spokesman to do all the talking, had lost his timidity.
“Given the circumstances, AMR is left with no choice but to explore all available options, including legal recourse, in response to the board’s actions,” Rice said. “The decision made by the county Board of Supervisors does not align with the best interests of the community and the patients of this community. The proposal selected by the board puts 29 fewer ambulances a day on the road than what AMR proposed. The community and our hard-working employees will be negatively impacted by the decision today.”