The complicated system that is the Austin-Travis Co. EMS is nationally recognized for saving lives. As Austin continues to grow, can the system save itself?
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Despite that simmering issue, the agreement between the city and county has for years remained relatively unchanged. Although the majority of calls for service still come from inside the city, explosive growth in the county over the last decade is now causing county officials to reconsider how EMS services are delivered. And there is now more at stake than simply the provision of paramedic care and ambulance service that ATCEMS provides, county officials say. Consider, for example, the issue of the county's Emergency Service Districts and the power of Austin's extraterritorial jurisdiction (ETJ).
Among the various taxing entities in the county are the 14 ESDs, which respond to fire calls and provide first response for medical emergencies outside the city of Austin – just as the Austin Fire Department does within city limits. As the county's population has grown, the demands on the ESDs have increased, in many places stretching thin their ability to provide services – an issue compounded by the city's annexation of tax-rich properties in its ETJ. That happened recently to ESD 11, which is responsible for 114 square miles of Southeast Travis County. It's a modest district, without the property-rich tax base of, for example, Lakeway or Bee Cave. The district would have gotten a nice bump in revenue – to the tune of at least $1 million per year, says ESD 11 Chief Ken Bailey – with the development of the Circuit of the Americas Formula 1 track in Elroy, in the heart of ESD 11. Then the city of Austin carved a little path eastward from the previous city limit to encircle the track. That leaves Bailey with roughly $2.8 million in 2014 to fund personnel and operations at three fire stations that serve some 30,000 people.
While the annexation issues may be equally vexing on the county's west side – 65% of the revenue in West Lake Hills is in Austin's ETJ, says Bailey – the tax base there is more affluent, allowing for larger budgets for the ESDs. In other words, the 10-cents-per-$100 taxing power of the ESDs is the same but certainly not equal, though their responsibilities are. All together, the county's ESDs have roughly $44 million a year to spend, says Bailey, money that now is unevenly parceled out and that will be increasingly crippled as Austin continues to grow.
"Potentially, if the city of Austin grew to its farthest borders and butted up against everything else, the ESDs have one-third of the current budget ... to operate on," said Bailey. "How do you sustain that?" And as it stands, the majority of calls for service in the ESDs come from the less affluent areas and are, as with AFD in the city, medical-related calls. If the city swallows up the ESD budgets, how will they be able to continue to serve higher-need, lower-income, and other rural county residents?
Perhaps no one better understands the pressures facing the ESDs – and, by extension, the county as a whole – than Danny Hobby, the county's executive manager of emergency services. Hobby is tasked with overseeing the contract between the city and county for ATCEMS services and is also the go-to guy for ESDs seeking county help to fund their operations. The question now facing Hobby and the county is how to address competing needs while ensuring all residents have access to high quality fire and EMS services.
With the support of Commissioners Court, Hobby is taking a broad approach, meeting with various stakeholders – including ESD commissioners and chiefs, representatives of the county's smaller cities, and ATCEMS and Austin officials – to try to determine how the county will address its growth issues. In May, Hobby got the nod from Commissioners to begin looking into a variety of models for providing countywide fire and EMS services. In addition to staying the course with ATCEMS as it is currently configured, the county is also exploring other service models, including whether it would be feasible to create a countywide fire department that would essentially consolidate the ESDs, and whether there might be other methods of providing EMS paramedic services to county residents – perhaps by further consolidating into a countywide fire-based EMS service. "Our residents deserve the most appropriate resources and response we can provide them, and our taxpayers deserve the due diligence necessary to make sure the cost of service is balanced and reasonable," Hobby wrote in a memo to Commissioners.
The suggestion that the county should look at other ways of delivering emergency services is not new. In 1998, county officials circulated a planning document that proposed just that: a countywide fire-based EMS service. For whatever reason, says Hobby, the idea never went anywhere. Now, he says, in light of the increased county service calls and the shrinking ESD budgets, the county must focus on its future: "here's the thing with the [ESDs], you're seeing that they're having fewer fires and more medical [calls] ... some of them are 75-80% medical" calls, he said. "You've got to now start paying attention to that and [ensure] that you're addressing that as the demand ... increases. But when you have lower funding [for the ESDs] and when you have resources that are limited ... there's got to be a give here. We've got to figure it out."
What About Consolidation?
Not surprisingly, the fact that the county has renewed its interest in talking about alternate service-delivery models for EMS has caused consternation, most notably within the ATCEMS Employee Association. To union President Tony Marquardt, the notion of breaking apart the agency as currently configured is a bad idea, one that would lessen the quality of care for county residents.
Currently, ATCEMS is the region's largest agency employing paramedics – professionals with the training and certification to deliver advanced care, including the ability to administer cardiac drugs, for example, or to intubate a patient. (The county-run air ambulance, STAR Flight, which also answers EMS calls, employs nurses and a small number of paramedics.) Employees of the ESDs, and of AFD in the city, are trained not only as firefighters, but also as basic- or intermediate-level medical technicians. Because of their numbers, the ESD or AFD employees are more likely to get to a call first and are able to offer basic care until more advanced paramedic providers arrive. Because all of these providers – roughly 2,000 in total around the county – operate under protocols designed by Medical Director Hinchey and his team at the medical director's office (and every first responder and paramedic in Travis County works under Hinchey's medical license), residents of both county and city are offered the same quality of care regardless whether they're living in the Austonian or in Webberville. "[T]he reason [the current system] still works better than some of the alternatives ... is that we have a unified system," says Marquardt. "We have protocols and resources going to the same place."
Nevertheless, Hobby's determination to put all the pieces on the table and to figure out what will work best to build a complete picture of service for county residents has many people inside the ATCEMS universe nervous about its future. Does this mean the county wants to secede from the partnership? Hire its own paramedics? Contract for ambulance transport with a private company? Does it not appreciate the level of care the paramedics offer? Will jobs be lost?
Ultimately, Marquardt says that he's concerned that the county – perhaps under pressure from some of the ESDs – will pull away from ATCEMS in an attempt to save money in the short-term, while in the long-term crippling the possibility that patients in need of care will have effective access to those services. A fractured service, or two separate services, is not a good idea, he says: What's actually needed is to add more resources – additional ambulances and advanced medical care on top of the eight ambulances the county currently houses at various ESD fire stations.