When someone calls 911, there must be, and will be, high-quality patient care sent to help, at all times. In the past year, the issue at hand has been about sustainable funding and continuing to deliver a high-quality Emergency Medical Services (EMS) system to the City of Fort Worth and surrounding areas.
In May 2024, the Fort Worth City Council approved the EMS Ad Hoc Committees recommendations, which include establishing an EMS system within the Fort Worth Fire Department. This will ensure that the EMS system for residents and visitors is financially sustainable, responsive, timely and focused on high-quality patient care. Current recommendations include:
- Focus on three categories: interfacility transports, EMS system changes and governance.
- Interfacility transports are to be removed from the 911 call system and privatized.
- Primary governance will move to the City under the Fort Worth City Council.
- Advisory boards will be created to better represent member cities, first responders, and the medical/clinical aspects of patient care.
- Service-level agreements will be created to memorialize EMS structure/relationship with participating member cities.
- Create a single-role civilian position within the Fire Department.
- Maintain independent medical direction keeping the Office of the Medical Director independent from the Fire Department.
Fitch & Associates, the consultant hired by the Fort Worth City Council to evaluate the current EMS model and provide a comprehensive study, will manage the transition of the EMS system from MedStar to the Fort Worth Fire Department and implement the process in partnership with the City of Fort Worth, the Fort Worth Fire Department and MedStar. There is an anticipated 12- to 18-month timeline, which includes a communications plan for stakeholders and end users of the EMS system.
The Fort Worth City Council, by separate resolution, will create two advisory boards in support of the EMS system, including an EMS Advisory Board and Medical Control Board. They will also enter an agreement with the other member cities and transition the EMS system to the Fort Worth Fire Department. The City of Fort Worth will continue to meet with member cities to align on next steps.
Background
In 2023, the City recognized the rising costs of EMS delivery and the stagnant revenues affecting the MedStar EMS delivery model.
- The City began an examination into solutions to ensure the long-term viability, stability, efficiency, and success of the EMS system that serves Fort Worth and other member cities.
- An Ad Hoc Council Committee on Emergency Medical Response was established to provide support and guidance to have a financially sustainable, responsive, timely, and high-quality, patient-centric EMS system. The committee conducted regularly scheduled public meetings where Fitch presented findings and recommendations to City staff and other key stakeholders in the medical community.
Fitch reviewed all aspects of the EMS process, including operational performance, personnel and staffing models, fiscal performance and governance.
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In April 2024, Fitch provided the City and the Ad Hoc Committee with its final report concerning the EMS Comprehensive Study, including recommendations concerning the system’s governance and operation.
The Study
- The interim report from Fitch was a comprehensive study of the current EMS system and compared it to 20 other communities nationwide, looking at governance issues, organizational structure, operations, response times, billing and revenue, and all costs and expenditures.
- The current EMS system did not deploy sufficient resources and had less personnel available to meet the desired response time objectives in 2023. The system calls significantly exceeded established standards for best practice.
- If the system were resourced to control for calls, then response time performance could potentially be improved by as much as 5.5 minutes (from the current 13.5 minutes to just an 8-minute travel time for all emergency 911 responses).
- The City of Fort Worth actively engaged with member cities and other stakeholders regarding EMS system governance.
MedStar Background
- MedStar operates as a public utility model, under the direction of the Metropolitan Area Emergency Medical Services Authority, to provide emergency medical services, including ambulance care, to Fort Worth and 14 surrounding cities.
- MedStar funds the majority of its services from fees collected for those services from health insurance and government programs, such as Medicare and Medicaid.
- Between 25 and 30 percent of EMS calls resulted in no form of payment (lack of insurance or decreased state or federal reimbursement). Combined with supply chain issues and soaring personnel costs on the capacity of the healthcare industry, MedStar was spending more than it was taking in to maintain the current level of services.
- Many other EMS systems are facing similar challenges.
- Because of funding from health insurance and government programs, the City of Fort Worth, along with other MedStar member cities, has not supported MedStar financially since 2009.
- As the Authority’s largest customer, Fort Worth accounted for 90 percent of its call volume and was represented by five of nine seats on the Authority’s board of directors.
Frequently Asked Questions
What does success look like?
Success is a long-term, financially sustainable EMS model that provides quality care for patients for years to come. The study will examine structure, governance, and financing for the EMS system and MedStar.
How is the Fort Worth Fire Department working with MedStar and how could this affect the department?
Since 1986, the Fort Worth Fire Department and MedStar have shared the common mission of providing the highest level of care that is in patients' best interests. The Fire Department regularly works with MedStar and remains committed to providing a high level of service to the community. Their crews work closely together daily.
How long has the MedStar Board been discussing fiscal issues and alternatives?
Since 2019, MedStar’s leadership team, in collaboration with their Board of Directors, took steps to prevent, or at least delay, the opportunity for expenses to exceed revenue. At the time, the financial challenges MedStar faced were anticipated to take place further in the future, and MedStar leadership and the Board of Directors kept member cities aware of the challenges that seemed to lie ahead.
How much does the City of Fort Worth contribute to subsidize MedStar?
Since 2009, the City of Fort Worth, along with other MedStar member cities, has not needed to contribute any financial support to MedStar. MedStar has supported itself through fees from health insurance and government programs like Medicare and Medicaid. The COVID-19 pandemic caused extreme decreases in MedStar revenue and other health care organizations such as hospitals and clinical practices. In 2020 and 202021, MedStar requested federal CARES Act funding through its member cities. The City of Fort Worth allocated a one-time payment of $606,400 in federal CARES Act dollars to MedStar in addition to other member cities collectively providing $20,000 of additional CARES Act funding.
How did MedStar operate without City funding?
MedStar utilized reimbursement from private and government insurers, like Medicare and Medicaid, for the services provided. Because of that third-party funding, member public agencies had not supported MedStar financially since 2009. A third-party cost reporting firm confirmed that MedStar had been the lowest cost provider in Texas from 2012 through the most recent cost report in 2022.
What steps has the MedStar Board and management taken?
- The first priority remained in meeting MedStar’s core mission of providing exemplary, quality, efficient patient care with the highest quality people.
- In October 2020, MedStar’s Board and management supported communication, and adoption, of the first increase in fee schedule in over 10 years, which was implemented in February 2021 resulting in $3 million of additional revenue.
- MedStar’s Clinical Department was integrated into the Office of the Medical Director (OMD) in 2015, moving three coordinator positions to OMD. No positions were eliminated in the merger, but reduced training time by approximately 50%.
- MedStar’s Training Academy was integrated into OMD in Spring 2020, moving one coordinator and one administrative position. A manager position and instructor position were eliminated, saving $200,000 per year.
- In 2019 and 2020, outsourced building and stretcher maintenance resulted in an annual savings of $100,000 per year.
- Evaluated contractual opportunities for better pricing through consolidating vendors or purchasing from different vendors.
- Outsourced most of the billing functions which reduced headcount and increased collections in 2021 and 2022.
- In 2020 and 2021, MedStar requested $700,000 of CARES federal funding allocations from member cities to offset anticipated lost revenue associated with the COVID-19 pandemic. Actual lost revenue was over $1.7 million.
- Eliminated three positions in 2023 and outsourced and redistributed responsibilities resulting in anticipated savings of $100,000 in 2024.
- Transitioning from diesel to gas ambulances in 2023 and 2024 estimated a $500,000-$750,000 savings upon full implementation.
- Worked with the state and federal legislators to pilot a program that pays for services rendered in the home, which was uncompensated before this change.
- MedStar leadership and board continued to work diligently to find cost savings while maintaining service levels.
Is MedStar a private contractor?
No. The City of Fort Worth and its member cities created MedStar as a public utility model, under the direction of the Metropolitan Area Emergency Medical Services Authority. As the Authority’s largest customer, Fort Worth accounts for 90 percent of the Authority’s call volume and is represented by five of nine seats on its board of directors.
Are other cities experiencing similar issues with EMS?
The declining financial status of EMS systems is an issue across the country, forcing many municipalities to evaluate their models. According to themunicipal.com, “The EMS system is under pressure from various sources and faces significant change in the coming years. EMS agencies face financial pressure from increasing costs coupled with flat or decreasing reimbursement; difficulties in recruiting and retaining personnel to staff ambulances … all coupled with an aging population and increasing number of calls.”