Pinellas County is the most densely populated county in Florida. Situated on a peninsula in the Tampa Bay area, it includes 280 square miles with a population in excess of 900,000 and hosts more than 13.5 million visitors annually.

The county is unique due to its barrier island geography, demographics, and number of local government units involved in emergency medical services (EMS). The paramedic ambulance service provider for Pinellas County provides service levels and clinical outcomes for a disproportionally older population. Providing this level of service has become increasingly expensive during its 30-year history.

The service provider Sunstar operates under county authority as a unified advanced life support (ALS) EMS system that serves 24 local governments and unincorporated areas ranging in population from 78 persons to more than 250,000. It functions through a single 911 center and contracts with 18 fire departments for medical first response. Emergency and nonemergency response and transport are provided under a competitively procured, performance-based contract. 

The Financial Predicament

In recent years, concerns related to the system’s financial sustainability have grown. This led to the search for solutions resulting in the submission of two controversial proposals to the Pinellas County Board of Commissioners, which also serves as the county’s emergency medical services authority.

The initial study’s primary recommendations included the elimination of ALS first-responder rescue units and expansion of ALS engines. The report, prepared by Integral Performance Solutions (IPS), applied a standardized cost approach for ALS services.

According to press reports, the study contained numerous errors, including misstating the number of fire districts in the county, grossly understating some firefighter salaries, and using outdated financial information. In short, it was widely panned by city, fire district, and fire officials who said the plan would reduce the quality of care.

The second proposal, developed by two local firefighter/paramedics, outlined an approach in which local fire service agencies would assume first- response and transport responsibilities. The county staff’s analysis indicated that the Sanford/Millican Plan would dramatically increase costs; result in hiring hundreds of government employees at a higher salary, benefit, and pension cost; and increase the cost of the current EMS system by $14 million annually with no guaranteed performance standards.

County officials became embroiled in a dispute with local fire departments over the two plans. Eventually, the state legislative delegation got involved requesting further financial analysis of the competing plans. Pinellas County’s current EMS system is governed according to rules set up by the special act that created it. Changes would require an amendment by the state legislature.

Analysis Process and Engagement Strategy

County Administrator Robert LaSala insisted that additional study was necessary to assess the operational feasibility of the two approaches. A detailed request-for-proposal (RFP) requiring the intricate matching of operational and fiscal data from all agencies was prepared.

Former State Senator James Sebesta chaired the committee that evaluated the RFP responses. Even that process became controversial when the committee recommended the high bid from our group, Fitch & Associates.

Determined to find a more affordable way to deliver countywide emergency services, the commission voted four to three to approve the study. The vote occurred after two and a half hours of debate that resulted in the commission directing LaSala to broaden the scope to operationalize not only the IPS plan, the firefighter’s plan, and the current system, but also other scenarios to find the best solution.

During the seven-month consultation, the team convened on-site meetings with elected and appointed officials at state, county, and local levels. Fitch also met with fire agency management, labor representatives, ambulance service management, members of the EMS advisory council, hospital administrators, medical control board members, and the county medical director. It toured the county communications center, Sunstar Dispatch, and Sunstar operations, and met directly with fire chiefs.

A “snapshot in time” of the operational characteristics of the various proposals was simulated using industry accepted, commercially available software and call data taken from the historic computer aided dispatch records over the period of fiscal year 2010–2011. The operational characteristics extracted from these simulations were then combined with cost data from the historic record for each district to calculate costs of the various proposals.

The software simulation process was vetted with fire chiefs, labor representatives, and other personnel in numerous meetings starting in mid-October 2012, with the final series of meetings in early May 2013. At the center of the study methodology was the use of sophisticated simulation software that allowed system participants to visually observe the operational impact of the different model configurations for the system’s 141,000 EMS responses.

The simulation software that was used allowed fire chiefs and local officials to validate each potential change input that was made to the system and actually watch the units dynamically respond under each scenario. It built trust among the parties because a significant portion of the analysis was accomplished with the parties in the room watching what was occurring. Participants’ input was also used to optimize several additional plans to present the best possible operational scenario on the fire department’s behalf.

Communication with the county public safety services personnel was ongoing through biweekly conference calls and status updates. Cost information was obtained from the County Public Safety Services Department, and fire agency personnel costs were confirmed and amended by each individual agency.

Results of the Analysis

While the process was designed with high levels of transparency and stakeholder engagement, its primary mission was to present objective data for decisionmakers. To maintain a level playing field, current response time and clinical requirements were held constant across all models. The simulation and analysis identified key service attributes and costs of these five distinct approaches.

Current system.The current Pinellas County EMS system achieves some of the highest clinical and response-time benchmarks in the nation. It operates with 103 fire first-response units and 70 ambulances with total annual crew costs of $112 million. The governance structure is well defined with both fire and transport agencies operating under strict performance-based contracts.

IPS model. This approach achieved countywide response time targets and decommissioned 25 apparatus and 150-plus firefighters. It had annual crew costs of almost $91 million but required additional annual fleet costs for heavy apparatus of $5 million.

In short, this model is theoretically achievable but lacks the realistic approach to make it implementable. Pinellas County fire and EMS are not in a state of disrepair that would require such a drastic cut. This finding, however, serves as an operational definition of excess reserve capacity in the system.

The objective finding that the system has excess capacity was the most important single lesson to be learned from the IPS proposal. This model could potentially save $16.3 million in crew costs if implemented. 

Sanford-Millican model. The Sanford-Millican proposal called for a complete change in the structure of the Pinellas County EMS system. Sunstar was to be decommissioned and responsibility for medical transport transferred to the 18 independent fire agencies.

The structure of the resulting system did not conform to the requirements of the county’s EMS ordinance. Many of the consolidated administrative and infrastructure functions of the current system would be dispersed among the 18 independent fire agencies. For purposes of costing this proposal, we assumed that the 18 fire districts would execute these previously consolidated functions at no increase in costs over the current system.

This approach achieved countywide response times. It had crew costs of almost $111 million. A key finding of the simulation, however, made it clear that the crew utilization levels are not safe to implement. The other key finding was that the new governance structure required would be extremely difficult to implement and maintain. If implemented, this model could potentially save $1.2 million in crew costs compared to the current system.

Sanford-Millican optimized model. This approach used the framework above and met countywide response times. Because crew workloads were unreasonably high in the previous model, this approach normalized workloads to recommended levels. This model’s cost is significantly higher than others at almost $121 million and represent an $8.2 million dollar increase in crew costs.  

CARES plan. The acronym CARES stands for Communitywide Alignment of Resources for Efficiency and Service. The model incorporated multiple stakeholder ideas, including considering a number of hybrid models. It was a difficult task given the core mandate not to negatively impact clinical or other service levels.

We balanced the risk of change with economic value obtained and used an intermediate approach, including continuing to use fire units to first respond to all medical calls. Fire becomes the primary responder on lower acuity calls, significantly reducing the number of assignments to which the transport system responds.

CARES maintains a balanced inventory of apparatus matched closely to call demand and retains the current administrative functions and infrastructure.  The crew costs of this model are $105.7 million annually and represent a savings of $6.3 million over the current costs. 

A Positive Result

Despite a split vote at the initiation of the project, at its conclusion the County Board of Commissioners unanimously endorsed the CARE plan. The work will continue into next year in collaboration with EMS partners countywide.