For-Profit EMS: Putting Georgia at Risk?

Emergency Medical Services, or EMS, is a vital part of our public safety and healthcare systems, but it has become increasingly privatized since 2008. Georgia has only vague standards for EMS providers, allowing some companies to operate with very little oversight.

National EMS is the for-profit healthcare provider in Athens, Georgia. How do they rate in terms of response times?

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EMS is Almost Completely Unregulated in Georgia

Take a moment to listen to this 911 call from Dunwoody, Georgia from last year. It took over 20 minutes for the ambulance to arrive. By then the parents and a child needing treatment were gone – they gave up and decided to drive to the hospital themselves. The city of Dunwoody had already issued a Declaration of EMS Emergency with the Department of Public Health earlier that year. They did so because of some extremely delayed ambulance response times like this one, and poor behavior by their private EMS provider, AMR.

This isn’t just a problem in Dunwoody. When it comes to regulation, Georgia has only vague standards for EMS providers, and that leads to weak oversight of the system. That’s according to a 2019 investigative report by the Atlanta Journal-Constitution.

So, how are we doing here in Athens? To find out, I sat down with Bob Gadd and Sam Rafal, who both have experience working as EMTs. Bob is a paramedic who worked for Saint Mary’s for 33 years, starting in 1980. At that time, Athens had two ambulance services, one for each hospital. But in 2009, National EMS took over for both services.

Bob worked for National EMS for 3 years, but he quit in 2012 due to ethical concerns, and turned whistleblower.

Bob Gadd: “What I discovered working there, pretty quickly is that… the quote I had to describe it is that they put profit over patient care. They would literally use the last ambulance in the county to take a non-emergency transport.”

Bob and Sam have been going to mayor and commission meetings for years, speaking to anyone who will listen about the dangers of for-profit EMS and the need for change.

Bob Gadd (speaking to the mayor and commission): “This is literally a life and death issue that affects, potentially everyone here and everyone in the entire county.”

I first met them in 2017, and they quickly convinced me that this issue should be getting much more attention. That’s why I’ve been working with them as part of Athens for Everyone’s EMS Response Initiative.

So, what issues do they have with National EMS? And more broadly, why is privatized public safety something we should be concerned about?

The Drive for Profit

Making money isn’t a bad thing. We’ve all got to put food on the table, including the paramedics in Athens who work for National. I’m not at all questioning their dedication to public safety or to patient care. But National EMS has always operated for-profit, and to make matters worse, last year they were bought out by the larger company Priority Ambulance, which in turn is partially owned by Enhanced Healthcare Partners, a Wall Street private equity fund.

When EMS comes “Under private equity ownership, some ambulance response times worsened, heart monitors failed and companies slid into bankruptcy,” that’s according to an in-depth investigative report by the New York Times.

The drive for profit leads to lower paramedic pay and to slashing costs in other areas as well.

Inadequate Training

Emergency Medical Dispatch, or EMD, is an established protocol for 911 dispatchers across the country. It provides for on-phone instruction to the 911 caller, to guide them in CPR or in other forms of care and safety until an ambulance can arrive. National EMS dispatchers are apparently not all trained on EMD, making their dispatching almost useless in some emergency situations. How do I know?

On November 28, 2017, a couple living near Athens discovered that their infant was not breathing. They got in their car and started heading for Piedmont-Athens Regional. They called 911, and were transferred from Madison county to the ACC dispatch center and then to National, when the call dropped. They called 911 again, were transferred again to National. The National EMS dispatcher unfortunately didn’t give CPR instructions. He didn’t coach them at all, in any way. Their baby later died.

On June 4, 2018, Mr Saheed Snow was shot in the chest on East Carver Drive in east Athens. National EMS sent an under-trained basic ambulance, staffed only by EMTs, not by paramedics. If an advanced unit was sent instead, his odds of living through this trauma could only have improved. Unfortunately, he also died.

It’s impossible to say how often under-trained basic ambulances are used by National, or how many of their dispatchers are not trained on EMD, since they don’t give this information to the public. But we do know of at least these two times when the lifesaving skills of a paramedic, and of an EMD dispatcher, were needed, but were not available.

National responded to this concern by saying the basic unit was the closest one available. But that doesn’t answer the question why was an advanced unit seemingly unable to respond in time?

Slow Response Times?

National EMS' contract
The relevant page of National EMS’ contract with the hospitals showing their response time expectations.

Response times are the standard by which EMS has been judged for decades. For some patients, such as those suffering from heart attack or stroke, the difference of even just a minute or two could mean life or death. The National Fire Protection Association 1710 standard is 8 minutes and 59 seconds for an advanced ambulance to arrive on scene. It’s not legally binding, but it is mentioned in National EMS’s contract.

So, how do the response times of National EMS stack up? Well….National has been in the news a lot lately, and not in a good way. In Morgan county, a woman named Donna Martin was stung by a wasp in July of last year. Mrs Martin had a severe allergic reaction and needed immediate medical attention. The National EMS ambulance didn’t show up until after 28 minutes, and unfortunately she died. It was tragic, and completely preventable.

Back in Athens, a couple in Winterville have a child who suffers from intractable epilepsy and sometimes stops breathing when he has seizures. The family has had to call 911 on 9 occasions since January of last year. Each time, they say they’ve received an extremely slow response, each being over 15 minutes and some being over 20. Fortunately, the child is still alive.

There are more stories like these, giving at least circumstantial evidence that National EMS is probably not meeting their required response times. Bob and Sam have tried for years to secure the direct evidence – they want the actual data. Last year, they succeeded. National refused to hand it over, but they were able to get the data by placing an open-records request with the state Department of Public Health.

Sam Rafal: “We got the raw data, and it was horrifying.”
Bob: “Yeah, it was.”
Sam: “Way worse than I thought it was gonna be, and these are all in a column that says from the Department of Public Health, 911 emergency response. And what we found is that out of about 50,000 calls, between 2014 and 2017, that 31,055 of them exceeded the standard.

The data they gathered was checked out by a CPA for verification. They found that National responds to, on average, only 39% of calls at or below the 8:59 standard. Remember, they’re supposed to respond to 90% of calls in that time-frame. This data was published by Athens for Everyone last year. In response, the hospitals released a statement of confidence in National EMS. Is the data from the Department of Public Health inaccurate or misleading in some way?

At the recent work session, Dee Burkett of Piedmont-Athens Regional presented data from 2019 that seemingly show National is actually meeting their response time requirements this year. What could account for that? Have they suddenly improved?

Slide showing a map of Athens-Clarke and Oconee county with National EMS' data.
Data presented to the mayor and commission showing National EMS’ 2019 response times in Athens-Clarke and Oconee counties.

The difference between the datasets is that Burkett’s data only includes cases that National considers high-priority, or priority 1. These are times when they ran lights and sirens and had other cars pull over for them so they can could get on scene more quickly. Experts say that not running red lights should only add between one or two minutes to response times. So this can’t account for the difference between the datasets by itself.

What’s going on here?

Sam and Bob feel that the data presented in the work session is manipulated and is not reflective of the true numbers. We can’t tell unless they show us the raw data, but they continue to refuse to release it.

Lack of Transparency

So, we know that National won’t let us see their response time data. Will they at least share this data with the mayor and commission? No. Even they have not been able to even see the data yet. ACC does have two representatives on the EMS Oversight Committee. Surely they’ve seen the data? According to Sam, we shouldn’t bet on it.

Sam: “I don’t think they’ve ever seen the raw data, to be perfectly honest.”

Dee Burkett more or less confirmed this at the mayor and commission meeting, saying that the data has not been examined in detail by the Oversight Committee in four years.

These Oversight Committee meetings are not open to the public, which may in fact be illegal, a violation of state sunshine laws. Every member of the committee is forced to sign a non-disclosure agreement! We have no way to tell what’s actually happening.

Erosion of Confidence

The lack of transparency, accusations of poor response times, incomplete training, and, in the background, a Wall Street private equity firm has all lead to an erosion of public confidence.

Sam: “If I ever need an ambulance, throw me in the car, run me to the hospital, don’t call 911.”
APN: “Wait, who said that?”
Sam: “Well, I was being told this by police officers.”
APN: “Athens-Clarke county police?”
Sam: “Correct. And UGA.”

Commissioner Patrick Davenport: “A kid cracked his head open two weeks ago, and the mother complained it took 22 minutes for an ambulance to get there. She called me, almost brought me to tears, but like… my mom, she was on the floor, she was just screaming and hollering, she could barely breathe. The ambulance never came. My next door neighbor down the street, he fell and hit his head on the door. The ambulance never came. It’s so bad in district 1 that people say that it is best for you to just drive to the hospital instead of calling EMS, and certainly, in the past when citizens of Athens-Clarke County has called me, that’s what I tell them.”

This erosion of confidence is a serious issue that needs to be addressed. People need to have faith in our emergency care providers. We could have the best trained providers and the most extensive service in the world, but if no one calls 911 anymore because we don’t trust it, it doesn’t do us any good.

We need to see the data, and the Oversight Committee meetings need to be open to the public.

Commissioner Mariah Parker: “What is the fear of transparency with the EMS Oversight Committee?”
Dee Burkett: “There is no fear of transparency.”
Parker: “Okay, then why is it closed to the public?”
Burkett: “It’s private information.”

Personally, I’m skeptical of any for-profit public safety provider. I think we should consider moving to a public system.

The first step, I feel, is to have all 911 calls going to a central location, run by the county, as Sam and Bob have been advocating for. That means we’d get transparency for the data, because it would be subject to open records requests. Once we have the data, that’s when we can decide how we want to move forward.

Source Videos

911 excerpt of frantic mother calling for help (Athens-Journal Constitution)

EMS in Athens: an interview with Sam Rafal and Bob Gadd

Mayor and Commission Work Session (7-09-2019)

Priority Ambulance welcomes National EMS

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