By By JOHN EBY / Dowagiac Daily News
It may seem humdrum compared to responding to an emergency with lights flashing and siren blaring, but routine patient transfers are the income-producing "bread and butter" of Dowagiac Volunteer Fire Department Ambulance Service Inc. (DVFDAS).
"Transfers may sound like a luxury," two-month Ambulance Director Jackie Evans told about 25 people who attended a Cass County Democracy Club forum on the financial future of Dowagiac ambulance service Wednesday night at Round Oak Restaurant, "but the reality is that's our bread and butter to keep the emergency ambulance supplied and maintained financially."
The DVFDAS has transported patients from Dowagiac to as far away as Chicago, Iowa City, Ann Arbor, Indianapolis and Quebec, Canada.
Transfers account for 77 percent of the service's income.
Medicare and Medicaid restrictions limit that income, however.
Various levels of charges for which the service bills $475, $500, $575 or $850 for critical care transport (CCT), Medicare, which is where 56 percent of the service's income comes from, will pay $224.81 of the $500. The rest must be written off.
Medicaid, representing 14 percent of income, compensates the service $208.56 almost across the board. Blue Cross Blue Shield gives $452, but is only 7 percent of income.
"Two percent of our income is from municipal subsidies," Evans said. "The rest is private pay and insurance. This is our funding challenge. Our way to increase income is to take more patient transfers. We have stepped up to the plate and are doing a donation drive to increase our fleet of ambulances to three."
Evans' husband, Guy, is a lieutenant with the Fire Department. Her father-in-law, Bradley Evans, was a founding member of the service. She was previously City Manager Bill Nelson's secretary and served with the DVFD seven-member executive board of directors for 2 1/2 years. She became a licensed Emergency Medical Technician (EMT) almost three years ago.
The service serves 16,000 people in the City of Dowagiac, Wayne Township and portions of Silver Creek, LaGrange, Pokagon and Volinia townships.
It responds to 1,500 to 1,900 calls annually – averaging of five calls per 24-hour shift.
Of the two ambulances, one is always staffed at Advanced Life Support (ALS) or paramedic level. The other is licensed for basic life support.
Six Emergency Medical Services (EMS) personnel are assigned to three 24-hour shifts of 8 a.m. to 8 a.m. Two fulltime members, Evans and Office Manager Kathy McFadden, are on duty during business hours of 8 a.m. to 5 p.m. Monday through Friday.
Dowagiac founding an ambulance service was inspired by a man suffering seizures in the parking lot of the Buy-Low grocery store across the street from the fire station.
Firefighters felt "helpless" to help him except to free him from his car while waiting 25 minutes for an ambulance to arrive from Cassopolis.
The City of Dowagiac bought for the Fire Department two old Pontiac station wagon ambulances that could double as hearses. One was operable, with the other providing spare parts.
For training, volunteer firefighters took first aid. Later, five members underwent advanced training at the Chicago Fire Academy. The DVFD established a "Class Two" membership so their wives could be trained as ambulance attendants without learning firefighting skills.
Evans indicated the service is evaluating the feasibility of reviving ambulance service subscriptions.
Subscriptions entitled you to call an ambulance without receiving a bill. Non-members were charged $35, plus $1 for every mile transported.
Linda Keesler of Pokagon Township, one of the original 13 EMTs, recalled selling $10 memberships door to door to get the service off the ground because "we were in dire need of money. There are a lot of good people and good businesses in this town who would donate to this. The city and our townships here will really help you out if it's approached in the right way."
Today's version "would simply prevent you from having out-of-pocket expenses," Evans said. "Your insurance companies would still be billed."
County Commissioner Johnie Rodebush suggested, as Southwestern Michigan Community Ambulance Service (SMCAS) did in Niles, approaching each municipality it serves for a one-time charge to infuse some cash.
"SMCAS can charge up to $20 a year per household," Rodebush, D-Howard Township, said. "It's never gone to that, but one time, after the director committed suicide after swindling a lot of money, they did that to make up that amount."
Otherwise, "We pay about $10 and sometimes it's been less. A one-time charge of $15 or $20 could give you some money to buy some decent equipment. Go to Silver Creek Township – Supervisor Bill Saunders is right here – or Pokagon Township" and pitch the proposal.
Future facility needs depend on a system review that is underway.
Staffing two units around the clock requires larger living facilities.
The ambulance service shares space in the Fire Department, which has been on Dowagiac's long-term wish list for years.
The service, which the 1968 volunteer fire department established in 1970, recently sent out appeal letters to raise at least $8,000 to $10,000. Taking it from basic to paramedic quality could cost closer to $30,000.
Barry Yakim of Barry's Automotive Service facilitated the $6,500 purchase of a used ambulance (new runs $60,000 to $80,000), which despite being the same age as the older ambulance has a third of the mileage.
"It's in much better condition," Evans said. "We're hoping to transition that into our fleet and take our oldest ambulance and make that our back-up ambulance. We would like to keep it stocked as it is, so we're trying to raise the money to completely equip it to at least basic life support."
Creative Vinyl pledged to handle graphics on the new unit.
She ran through a list of equipment the state requires to be on an ambulance – splinting equipment, traction splints, stabilizing equipment and backboards, portable suction units, an automatic external defibrillator (the most expensive piece at $3,000) to restart hearts, basic bandaging gear, oxygen and airway supplies, a first response bag, an $800 "stair chair" for narrow spaces where cots and backboards won't fit, a Kendrix Extrication Device (KED) to immobilize injured spines, a blood pressure cuff, a glucometer to check blood sugars, staff personal protective equipment and a kit for delivering babies.
"That's the basic stuff," she said. "Down the line, we'd love to advance that unit to Advanced Life Support (ALS) or Critical Care Transport. To do that, an actual defibrillation unit. Those run $16,000 to $20,000. Portable vents used run $5,000 apiece. Immediately, we want to get a basic unit … Consistency is key to everything we do. We want to be responsive because we provide patient care transports to assisted living care facilities, nursing homes, hospitals and adult foster care centers. At this point, with the licensing levels we have available in Michigan, we literally can bring an emergency room into your home to work a cardiac arrest. Our paramedics carry several cardiac drugs that are meant to stimulate the heart and to respond to an electrical shock. They also carry medications for pain management. We want to continue to operate and offer this level of care, which to our knowledge is the highest that's ever been offered in Dowagiac. We want to continue providing that to the citizens of this community. We want to meet every emergency medical need this community has to offer. One way we can do that is by partnering with the community on donation drives such as this and fundraisers like our chili sales and spaghetti dinners."
At one time the DVFDAS did own three ambulances. The oldest unit, with virtually no trade-in value because it ran on a gas-powered engine, was donated to the city. The Fire Department uses it for confined-space rescue.
"The need for three ambulances wasn't there immediately," Evans said. "But we have a 1994 (with 150,000 miles) and a 2000 (which could conceivably last 10 to 15 years) that are getting on in years. We had an opportunity to purchase a used ambulance to replace that one. Our hope, in order to keep three ambulances, is to have one for use as a spare. Our next goal is to staff both ambulances on a 24/7 basis. Currently, we staff it fulltime from 8 a.m. to 5 p.m. From 5 p.m. until 8 a.m. we rely on our volunteers to take up the rest of that slack."
As care continues to improve in Cass County and across the nation, "The ability to transport a patient to a bigger facility gets more commonplace. We need to be able to say to our health care facilities that no matter what time of the day or night, if that patient needs to be moved, we will move them. Meeting that need for our hospital is our goal," Evans said.
"We need to have at least two ambulances," Office Manager Kathy McFadden agreed, "because the main unit stays in our coverage area for emergency calls. We never leave the area uncovered for transfers. The second, and third hopefully, pretty much take transfers back and forth. If there are no transfers, then we have two ambulances available for e-calls. If we don't have a third and one of the two ambulances goes down, we can't take transfers, and that's our bread and butter."
Evans said another goal is staffing each shift with a critical care paramedic. "A patient is ill enough that they either need a pump-operated medication intravenous – assisted with ventilation, helping them to breathe. Patients who are in that dire need need an even higher level of paramedic. This is a certification two of our staff have. We're hoping to get a third," or one per each of the three rotating 24-hour shifts.
Evans told County Commissioner David Taylor, D-Ontwa Township, expanding the coverage area would not be the answer to the fiscal crunch.
"We have a lot of small services around us and to expand our service would take from them." Spreading out might also threaten the 10-minute response for which the service strives.
How about consolidation then? wondered County Commissioner Ed Goodman, D-Silver Creek Township. Evans said it would be hard to merge Dowagiac's non-profit organization with, say, Coloma and its private, for-profit business corporation.
"We talked about it years ago when Life Care in Cassopolis started having budgetary problems," Evans said. "A countywide EMS service was discussed. All these services have been nursed from nothing to where they are now and they all run on different systems. Some run on subsidies, as we do. Some have millages. There's an area in Indiana trying to get a countywide EMS and we're going to be watching that. To date we have mutual aid and we partner and assist each other as best we can."
"We're trying to avoid a private company coming in and everybody paying a whole lot more in taxes," McFadden said. "We're trying to be self-supporting, the way we've been."
Another answer to Goodman's question, Keesler added, is "seconds count. Unless Coloma staffed an ambulance in our location … If you're dying and you're depending on another ambulance service someplace … Dowagiac will cover you in a matter of minutes. Seconds count."
Where Emergency Management Technician (EMT) coursework was once taught out of fire stations, now that being a paramedic is a profession and regulated by the state, classroom training is offered through colleges, including Southwestern Michigan College and Lake Michigan College.
The modern EMS field is 40 years old, originating in 1966 from a government-subsidized study.
EMS "exploded" in the 1970s with the help of the 911 and "Emergency" television dramas which promoted the "hobby" sideline into a profession. Legislation in the 1980s "made it the responsibility of each municipality, township or county to provide pre-hospital care within its boundaries and the establishment of recognized and regulated standards for training nationwide for ambulance personnel and the equipment required," Evans said. "These changes insured that regardless of where you live, if you became acutely ill, you would receive timely, proper emergency room care and transportation to the local hospital. Part of the '80s explosion was the levels of training going through the roof. We went from having EMTs to EMT specialists with more advanced training, and above that, paramedics came into play."
Stiffer training requirements and the advent of the two-income family eroded the volunteer base and hastened the shift to hired staff in the 1980s.
In 2000, the DVFDAS qualified for limited ALS licensure twice. Becoming a paramedic involves 1,200 hours of training and takes about a year and a half. ALS status with paramedics was achieved in April 2005.
"Volunteer paramedics are very rare," Evans said. "Nobody takes a year and a half of school to volunteer. This is a career for them. We have higher operation costs than we've ever seen before because we're an employer now. We maintain nine staff members with insurance. We've never asked for a tax base and we have no plans for that. We subsidize our income with the help of our municipalities, who get charged a per-parcel rate which is currently $10, and we're asking for an increase to $11 per occupied parcel," but that covers only 2 percent of the operations budget.