EMS Department
Response to Questions Regarding Budget
Question: Why have we not shared all the budget numbers with KWHI (Specifically The Spectator))?
Answer:
- We have. With 100% certainty, we have.
- We met with him in 2022 and stated we will meet with him at any time and we have yet to receive any requests to meet with him since that time.
- We disclosed the numbers in the budget last Tuesday (Sept 12th, 2023).
- We also have posted the entire budget online.
- There is zero possibility of not giving him or anyone the numbers. This is where the spectator, in our opinion, is simply causing confusion and misleading the readers. Why anyone would desire this for their community is a whole other question.
Question: In regards to the word “deficit” that keeps getting thrown around, what is the truth?
Answer:
There is NO deficit to speak of. We do not believe this was intentional by the outside auditor, but nonetheless, it is confusing to the readers. This is common auditor language and is entirely taken out of context by some in the community. The court expected, was shown, and voted on a subsidy amount every budget year. This was not a surprise, and was not overspending on behalf of the county or department. Please READ this in detail to better understand.
- Since its inception, the EMS department has been expected to produce revenue. Revenue in regards to EMS is not tax dollars. Unlike other public safety departments, where 100% of their budget comes from taxes, revenue in EMS is the collection of fees for services received through insurance billing (private and public - Medicare).
- Once the Court sets the EMS budget each year, we then get the most accurate projection of revenue from our outside billing company. The billing company can only project the estimated cash per trip (CPT) that we expect the insurance company will pay. Of course, they can not project the patient profile (amount of insurance) nor how many calls will occur. Therefore, it is a “projection.” The difference between the projected revenue and the budget is the amount we, as taxpayers, must pay for the EMS department. This is traditionally called a subsidy. The amount the taxpayers “subsidize” their local EMS Department.
Reminder: In all other public safety budgets for the County or City the entire (100%) budget is expected to be paid for by the taxpayer. There is no offsetting revenue.
However, in the Washington County EMS Department, it is expected we offset this cost with revenue. This has been the expectation since 2006 by three different county judges and courts. Never has it been the philosophy for EMS to be a profit center and actually make a profit (or have a zero subsidy) off of our constituents and visitors. If that philosophy changes, we would need to increase our rates and remove the exemption to bill patients for the full amount.
In fact, we are one of the few EMS Departments that exercise a government exemption allowing us to NOT BALANCE BILL THE PATIENTS. This means that after your insurance is paid as a taxpayer, you will not receive a bill for service (air or ground). Currently, we write off approximately $2,000,000 per year of potential revenue rather than take our taxpayers (mostly the elderly) to collections. This is how a private company will tell you they can provide this service for less. It's because they can not exercise this exemption and must bill the patient for 100% of the uncovered amount, leaving the patient with excessively burdensome bills or in a collection agency during an already stressful time. This becomes a travesty, increasing a patient's financial burden at a time when they are experiencing potentially extreme medical hardship.
Hypothetical Example:
If the EMS's total expected budget was $10,000 and the expected fees for service were $5,000, then the EMS Subsidy would be $5,000. In this scenario, 50% of the budget is expected to be subsidized by the taxpayer.
What we have found is the majority (and even a Journal of Emergency Medical Services (JEMS) 200 Survey revealed that EMS services are typically subsidized between 40-60%.
Actual EMS Department Example:
In 2022, your EMS department was subsidized by 18%, well below the average.
At the end of 2022, our amended budget was $5.66 million, and our total revenue was $4.61 million, leaving a subsidy of $1.05 million.
Question: Has the EMS "subsidy" been increasing over time?
Answer:
- Of course, it has.
- As has every other county budget increased over the last five years. Keep in mind that we have had an unprecedented medical pandemic during this period. That has changed nearly every operating protocol in the healthcare environment. In addition to the expense, the revenues have also been increasing, which has helped offset the budget increase.
- The amount our EMS subsidy increased from 2020 to 2024 (including rural paramedic development, air program, additional ground staffing, and salaries was $1.3 million.
- Over the same time period, the Sheriff/Jail budget increased by $1.78 million.
- Over the same time period, the Communications budget grew $712k
These can be found on the county website for fact-checking purposes.
Remember, "budgets" in these two departments are expected tax dollars spent. "Subsidy" in EMS is expected tax dollars spent. So, an accurate comparison of actual tax dollars is applied.
- What caused the increase?
- Inflation (cost and salary increases)
- Fuel cost
- Supplies
- Fleet Maintenance
- Most importantly, staffing requirements.
- The EMS Department has suffered a significant increase in call volume over the past ten years—a nearly 99% increase in requests for services (RFS).
- This subsidy typically increases as we add staffing. As volume grows over the next few years, the revenue increases. Reducing the subsidy. We have had years that this subsidized amount was as low as 8%, meaning 92% funded by revenue. This typically occurred when we were understaffed according to our volume, which is the primary driver of our EMS budget (staffing). There have also been early years with over 1 million dollar subsidies (2004/2005), which were years before we outsourced our billing department.
Question: What is the Cost of the aviation program?
Answer:
- As stated in June of 2022 in a meeting attended by the County Attorney, Treasurer, Auditor, and Court members. The program's expected annual cost for FY2023 is approximately $3.2 million dollars. The revenue generated was projected to meet or exceed that amount.
Leaving an expected zero subsidy amount to the taxpayer. - The Department gave the Commissioners Court three different proformas as potential expectations (worse, expected, and best-case scenarios). We are seeing the expected case scenario come true for the first six months of operations, with revenue currently outpacing expenditures. This was reported and revealed in our FY 2023 Quarterly report delivered to the Commissioners Court in June of 2023, with both local news media outlets in attendance.
- The program's cost was expected to increase the budget in 2022 by $1.5 million from June through Dec. 31, 2022. Which, retrospectively, it has. Total Cost was approximately $1.4 million, and total revenue thus far is over $1.3 million. Leaving $100k subsidy. Please keep in mind there is an additional $500k of revenue remaining to collect.
Question: The Spectator alluded to us “hiding costs” by not discussing the cost of the paramedics that staff the air ambulance. Is this true?
Answer:
Of course NOT. It's impossible to hide costs in local government. Not only was the cost associated with staffing fully disclosed in the proforma, projections, discussions, and every open meeting, but they are also very clearly depicted in the budget on the county website which provides actual true costs.. While this makes for an entertaining discussion, it contradicts the information on the county website. Unfortunately, it is also misleading to the general public that reads the spectator report. These costs are not only published in the budget. They were disclosed as projections before the court approved the program in public meetings.
- These numbers were fully disclosed to the court during the planning meetings. The estimated proforma for these positions have ended up well under budget.
- The Spectator knows this because we met with him after his first “spectator report” in 2022 and showed him all the numbers. Of course, those were projected numbers because the new program was weeks into operation. We now have actual numbers.
- However, we came in under budget, as discussed.
- The Spectator and others may not understand that for two budget years, the EMS department has been trying to increase staffing due to call volume, specifically since COVID-19. The pulmonary compromised patients become very sick and require specialty care that often is not close to home and resource intense.
- We have held off the additional staffing since the air program became county-managed because of sharing resources and genuinely being one team. The air ambulance handles 90% of these definitive care critical ill transports.
- What most people do not understand is that those "flight" paramedics are also functioning as ground paramedics routinely. If you removed the air division tomorrow, we would still need those paramedics to handle the additional volume added to the system. The cost of the staffing is in the EMS budget with or without the addition of the air program.
Six months of data shows:
- They filled 41 ground (24-hour) shifts from staffing vacancies.
- They filled 14 partial shifts for staffing vacancies.
- Performing over 26 ground critical care transfers when the aircraft can not fly due to weather restrictions.
- They responded as community or district squad responders 16 times.
Question: Did the Air Program cause an INCREASE to the budget?
Answer:
Of course, it did. Our best estimate is about 3 million.
- What do you mean by “best estimate”? As discussed above, costs are undoubtedly dependent on call volume, which makes it impossible to know the exact amount. While the Spectator likes to tout that we give different numbers, he is correct. We do not have a full fiscal year under our belt. All we can provide him with is the CY2022 cost at present.
- We do have the totals for the METRO cost for 2022 - $1.4 million.
Question: Did the AIR Program increase REVENUE for the EMS department?
Of course, it does. We estimate approximately $3.2-$3.5 million per year when the program is matured in its billing cycles.
Question: Does the air program increase the subsidy (taxes that we pay) after subtracting revenue?
- We do not believe it will. If it does, we think it will be between $250k-$500k
- Our earliest results show an expense of $1.4 million and revenue of over $1.3 million for six months of operations in 2022. We have the remaining $500k of revenue still pending payment for that period. It currently looks to exceed cost and therefore causes no increase to the subsidy (taxpayers-funded dollars)
Question: The real question that has never been asked is: Does the air program help our community?
Answer:
- We wish we could give you the actual names of those who have already been impacted, but HIPPA will not allow it. We have publicized several stories of actual cardiac arrest survival patients. Which seemingly never makes The Spectator report.
- The Spectator quoted Director Deramus in an article recently, citing, “Mr. Deramus thinks it's worth it.” That is a correct statement and a correct quote. He unashamedly does believe it’s worth it. We have also had many stories of patients who would tell me the same, and it allows him and this court the peace of knowing we are doing the very best we can when an emergency strikes a family member, a visitor, or a constituent of our county.
- We have, for the first time in our 45 years of existence, not just met “best practices” but are exceeding STEMI (heart attack) transfer times and stroke treatment windows and have had trauma patients in the hands of surgeons within 33 minutes of the actual car accident. These are phenomenal results and are impossible without the collaborative approach of our ground and air medical service.
- With over ten years of data trying to accomplish such standards by ground and outside air entities, it is impossible for our citizens to get the same time-sensitive standard of care that urban citizens receive without our in-county air program. This is NOT a slap at our aviation partners outside our county. They do the absolute best they can, but time does not allow them to be successful with our geographical parameters.
Question: The Spectator stated in his most recent spectator report that “they do not know the real numbers of the program because they all give us different numbers”.
Answer:
- The fact is all three numbers given were accurate.
- Mr. Hanath spoke about all three numbers. He gave FY 2022 complete numbers up to that date (September, 12th of 2023)
- He also cited the FY 2023 numbers of $8.3 million.
- Then, he (Comm Hanath) cited the budget being voted on for FY2024.
- We would also remind the readers that the revenue numbers are constantly changing (increasing for the positive). In contrast, the expense number at the end of a year is fixed and doesn’t increase. The revenue will increase for many months, and with the current insurance tactics and lawsuits, this can go on for more than a year. Why do we inform you of this? It's easy for someone to say they told us different numbers again when the revenue quoted today will be different than tomorrow's.
Question: The Spectator somewhat sarcastically alluded to Mr. Deramus "lying" regarding insurance companies paying slow. We would like to address this to the readers.
Answer:
- We believe this is also an attack on the character of our county employees. However, the truth is Mr. Deramus brought the subject matter experts in to discuss the court cases and IDR insurance (independent review) process back in April of this year. Holly Webber (Metro Aviation) and Kim Stanley (former Medicare claims agent and now VP of EMS/MC) discussed this issue with the court. KWHI was present for this specific workshop on EMS Billing practices. Since that time, two different Texas lawsuits have not just slowed but completely stopped insurance payment processing. While the court rulings appear to favor improving the process, it remains a slow process. The insurance payments resumed for about a month, and an additional lawsuit in Tyler, Texas, was filed in August of this year, stopping payments again. Commissioner Hanath cited these court cases in his comments during the budget vote.
- While the insurance processes are indeed frustrating, it's far from the mischaracterization of Mr. Deramus that the Spectator is perpetuating. Please feel free to view these rulings:
- August 24, 2023, the U.S. District Court for the Eastern District of Texas issued an opinion and order in Texas Medical Association, et al. v. United States Department of Health and Human Services, Case No. 6:22-cv-450-JDK (TMA III), vacating certain portions of 86 Fed. Reg. 36,872, 45 C.F.R. § 149.130 and 149.140 , 26 C.F.R. § 54.9816-6T and 54.9817-1T, 29 C.F.R. § 2590.716-6 and 2590.717-1, and 5 C.F.R. § 890.114(a) as well as certain portions of several guidance documents. As a result of the TMA III decision, effective immediately, the Departments have temporarily suspended all Federal IDR process operations until the Departments can provide additional instructions.
The initial TMA/LN IV court ruling before had suspended the IDRs on 8/3/3023 because the administrative fees were increased without proper notice and comment. The TMA/LN II case is currently in the appellate court again, with the plaintiff's arguments against the government's appeal due last week.
Question: Why is Mr. Deramus quoting different subsidy numbers than the Outside Auditor?
Answer:
- The Outside Auditor quoted a number that appears in the budget on page 50 of $1.66 million in subsidy.
- Mr. Deramus is responsible for tracking all expenditures and ALL REVENUE. Thus far, we have only discussed revenue as fees for service. Several years ago, we also asked Mr. Deramus to diversify the EMS revenue streams to include other forms of revenue (nonlocal tax dollars) and to ensure we “show” or demonstrate all the revenue that comes in for the EMS Department. In addition to the air and ground insurance revenue that Mr. Crane reports on. The additional funding sources that the EMS Department tracked for 2022 are:
- Donations Account
- Brazos Valley Council of Governments
- HRSA Revenue (Health Resources and Services Administration)
- CARES Revenue (COVID expense dollars due to overtime expenses occurred)
- TASPP Revenue (Texas Ambulance Services Supplemental Payment Program)
- Task Force Reimbursement
This additional revenue that the county received lowers the subsidy to $1.05 million (which is the number Mr. Deramus reported) for 2022.
Question: This question was not asked by the Spectator but we felt it was good to answer since he allowed the statement on his comment feed. "The EMS Department is flying more patients than needed to simply make revenue."
Answer:
100% not true.
In truth, this is one of the primary reasons we felt we needed to have direct medical director oversight and billing operations back in June of 2022.
Number of flights from our private vendor before the change to Metro in June 2022
2021 - total flights 753 under REACH
Number of flights after the change to Metro in June 2022
2022 - total flights 426 under six months of REACH and six months with Metro.
2023 - total projected flights 360 for a year as a county program with Metro.
We are actually flying nearly half the volume. The truth is the insurance providers will not reimburse us if we fly patients who do not qualify for the benefit of air medical transport. PERIOD!
Clinically speaking, we currently air transport less than 2.7% of our total request for services as a department. 97% of our patients get transported by ground ambulances.
They are the sickest of the sick patients we see.