Written by David Duncan (California State University, East Bay)
Contact David: dduncan945@gmail.com
Edited by Aimee Casey (Diablo Valley College)
Faculty Adviser: Nolan Higdon (California State University, East Bay)
The sun’s reflection off of the windshield of the Rural/Metro ambulance is a refreshing sight to the emergency medical technician crew during light traffic on the 980 freeway in Oakland, California. The crew is on their way to a hospital to await the next call. One partner discusses the joy of transferring to an Emergency Medical Technicians (EMT) position in San Francisco , then the discussion stops as the two partners focus upon a reckless and inattentive lane change by a gold minivan just ahead of them. The van then collides with a white SUV. Both cars spin violently into the railing at high speeds before coming to a stop on the shoulder within fifty feet of one another. The crew parks, turn on the emergency lights, and report the accident to dispatch. With equipment in hand, one partner approaches the nearest vehicle and the other approaches the second. The closest vehicle contains a mother with two children; the kids cry loudly while the driver sits stunned. The EMT asks questions to determine the extent of her injuries. She’s already reaching to the back of her neck and struggles to turn towards her children in the backseat. Assistance and medical attention are clearly needed but these two EMTs are not going to offer any. Instead, the mother is informed she will need to wait for another ambulance. Confused, she asks “Aren’t you the ambulance?”
This EMT crew drives in a vehicle that looks and sometimes responds like an ambulance. However, they are employed by Rural/Metro Ambulance Company. Rural/Metro is contracted to transport only Kaiser Permanente patients. Thus, they only use their EMT training when authorized by their company. If they encounter any other type of emergency, such as a car wreck, they are forbidden from using their EMT training. For the employees of Rural/Metro Ambulance, this scenario is neither the first nor the last.
The latter half of the twentieth century marked a dramatic reversal in many of the socialist ideals that propelled the United States out of the Great Depression and World War Two. After three decades, neoliberalism surged into the American mainstream with President Ronald Reagan at the helm of the movement. Neoliberals champion market ideals of privatization, de-regulation, low taxes, and a color blind vision of the world. Reagan’s Administration normalized the practice of replacing governmental agencies with private companies. Few industries were transformed as significantly as the medical field in which corporate heads became millionaires and billionaires at the expense of the sick and dying. Massive private firms were formed and eventually bought one another to create a massive syndicate with the responsibility of providing care in the pre-hospital setting in which seconds decide the difference between life and death.
Until the 1960s, pre-hospital care lacked official standards and training for ambulances, their staff, and the essential equipment on board.[1] Without defined specifications of an ambulance, private companies such as mortuaries utilized hearses for ambulance services in a morbid example of vertical integration.[2] After a government report in 1966 known as the Accidental Death and Disability: The Neglected Disease of Modern Society, the Department of Transportation earned the responsibility of setting ambulance standards along with the minimum training requirements for the crew on board.[3] The ambulance conglomerates in the United States today have taken the place of funeral homes. Subsequently, the firms relinquish responsibility from cities and counties in providing ambulance services to its residents.
Health maintenance organizations or HMOs follow a similar historical path of the ambulance companies. The 1930’s and 1940’s marked the beginning of payments by citizens into a group of medical professionals before illness or injury. In 1942, Kaiser Permanente was among the first of these groups. In response, individual doctors and hospitals fought against the conglomeration of medicine and were somewhat successful until the 1970’s.[4] Just seven years after the government set the first standards for ambulances, standards were applied to grouped health coverage. The enactment of the Health Maintenance Organization Act of 1973 (P. L. 93-222) provided a major impetus to the expansion of managed health care. The legislation was proposed by the Nixon Administration in an attempt to restrain the growth of health care costs and also to preempt efforts by congressional Democrats to enact a universal health care plan. The article goes on to identify this specific legislation as the point in which the United States health care industry began to shift towards a for-profit system.[5] These two forays by the government into changing the health industry in the United States gave birth to the multi-billion dollar entities that profit from the sick and dying today.
The for-profit business model used by many private ambulance companies assume that call volume will remain consistent on an annual basis with slight increases in the winter months due to increased cold weather illnesses such as influenza and pneumonia. Most companies earn profits exclusively off their ability to respond quickly to calls. Therefore, at the company’s behest, ambulance crews often admit to rushing through medical calls as quickly as possible in order to respond to the next call. Crews cannot and will not provide the same level of care to every patient under these circumstances.
Rural/Metro’s story in the contemporary world of privatized emergency medical services exemplifies all that is wrong with the industry. In 2012, Rural/Metro Ambulance established a transport operation in Northern California with the primary purpose of acquiring the Kaiser Permanente contract for the counties of Contra Costa, Alameda, and Santa Clara. The contract guaranteed exclusive ambulance service for the transportation of patients to and from Kaiser facilities as well as their residences. The contract was obtained by under bidding American Medical Response (AMR) with the promise of lower operation costs for Kaiser. This would be achieved through lower staff numbers and less ambulances running in the fleet. Accordingly, Kaiser set up a reimbursement system to only pay profits if Rural/Metro ambulances responded to calls on time more than 95% of the time.
The ability to respond to calls on time with fewer ambulances than the previous provider considering San Francisco Bay Area traffic, vehicle breakdowns, miscommunications, navigation issues, pre scheduled pick-ups, and emergency calls all spanning between Alameda, Contra Costa, and Santa Clara counties, was an incredibly daunting task. Tremendous pressure was placed upon the field crews to respond to calls as quickly as possible and/or to rush completing one call to respond to the next. Downtime is extremely important to a crew’s well-being and their ability to stay on top of their game. Constant fatigue leads EMT’s to burnout, injury, or not delivering the level of care and attention that is required of them.
One time during a weekly management meeting in which the statistical data of the week’s calls were analyzed. Fellow managers were thrilled that many of the crews had little to no downtime, no lunch breaks, and ran calls non stop for twelve hours. When the manager exclaimed it was “great news!” that the crews had not received any breaks, one employee muttered “for who?” only to be met with expressions of offense from the leadership. The view of the emergency medical services provided were narrowed down to statistics; numbers and percentages that led towards a profit. This type of thinking demonstrates the inherent problems with massive corporations managing emergency services. The business model does not apply to a type of work where human patients are at their worst, fearing for their lives, while the ambulance crews absorb the inherent mental and physical breakdown of suffering.
Another dangerous aspect of the contract between Rural/Metro and Kaiser, involves the deployment of Rural/Metro units to private residences. A Kaiser patient began the lengthy process of getting care by calling the centralized call center where an advice nurse would hear their complaint and often recommend that they come in to the hospital to be evaluated. The advice nurse then contacted the Kaiser Dispatch center who would call Rural/Metro to send an ambulance to the location. If a patient called Kaiser with an emergent complaint, they would have to personally pay for the 9-1-1 ambulance to transport their patient. If the Kaiser nurse had a Rural/Metro ambulance dispatched with a crew that was trained for basic-non emergency transport, and the two EMT’s decided to call a 9-1-1 unit, Rural/Metro would cover the costs. In the initial months of Rural/Metro’s operation, hundreds of patients were put at risk by Kaiser illegally delaying care. The self proclaimed “non profit” health care provider finally stopped when Rural/Metro Dispatchers and field crews complained that they were responding to calls well above their scope of practice. Rural/Metro was equally guilty of conducting its operations with a singular mission of increasing profits but this was not always the case.
Rural/Metro’s origins can be traced to a noble motivation and intention from which current operation procedures greatly deviate. “One evening in 1948, Lou Witzeman watched his neighbor’s house go up in flames because there was no fire protection in his small, unincorporated community. He knew something had to be done. Lou pooled together some money, bought a fire truck, and began the operation of a four-man fire department. He couldn’t collect taxes, so he went door to door, asking his neighbors to subscribe by paying an annual fee. “There was no master plan in forming the company,” Witzeman said. “I simply needed fire protection for my neighborhood, and I was determined to get it”. Rural/Metro was a facet of capitalism that was unmistakable; when the government could not provide an essential public service, an individual took it upon himself to solve the problem. Witezman held on to the company as it grew exponentially into operating ambulances, fire departments, and private security services.[7] In 2011, the equity firm lead by ex- Treasury Secretary Timothy Geithner, Warburg-Pincus, acquired Rural/Metro.[8] Opportunities for ethical questions abound when considering the implications of a large corporation’s ownership by an even larger financial firm who profit from illness. In fact, in 2016, the New York Times published an interactive article regarding the transition of ownership of public services from the government to private equity firms.[9] At the start of that vary same year, AMR, the medical transportation segment of Envision Healthcare Holdings, Inc., is acquiring Rural/Metro Corporation. The acquisition, to close in the fourth quarter of 2015, enhances Envision’s mobile integrated healthcare delivery capability.[10]
Possibly the tip of the iceberg in Rural/Metro’s questionable business practices was revealed when Santa Clara County Supervisor George Shirakawa Jr. was arrested on March 1, 2013 and plead guilty to charges of corruption and abuse of public funds.[11] A damning article in the Mercury News by Karen de Sà chronicles the interwoven suspicious activities by the supervisor and Rural/Metro. It started in December 2009 when Shirakawa and his chief of staff spent $1,742 of tax payer money on a trip to San Diego which was documented to the county as a visit to the WestMed Ambulance Headquarters in order to learn about their operations.[12] In reality, the supervisor was meeting with the Rural/Metro Ambulance, the only board member to do so. WestMed Ambulance is based in Hayward, CA, roughly a 50 minute drive from Santa Clara County and is a much smaller mom and pop style company that would lack the resources to handle a county wide contract.[13] He also had a meeting with the company’s lobbyist in San Diego before heading back to the Bay Area. De Sà also uncovered the numerous monetary donations Rural/Metro made to Shirakawa before his indictment and the vote he cast to give Rural/Metro the 375 million dollar contract. Six weeks before Rural/Metro signed a five-year agreement with the county, the company made an unusually large donation — $50,000 — to the local Democratic Party chapter. “[He] also accepted a $250 campaign contribution from the company’s public affairs director and a $50 ticket to a chamber barbecue from the company after it won the contract. In 2012, the PAC also spent $1,006 on behalf of Shirakawa’s senior policy aide and another $769 each on behalf of Shirakawa and Supervisor Dave Cortese, who also voted in favor of the Rural/Metro contract”.[14] These donations are not against the law, but remain suspicious when Shirakawa admitted to accepting cash illegally from a source that is still undisclosed. In 2011, Rural/Metro’s operations ended in San Diego amongst the city prosecutor investigating the company for abnormalities in their billing that could amount to millions of dollars in mistakes.[15] Santa Clara County is now left in the fallout of a corrupt politician and the company that is responsible for saving the lives of the citizens within its borders.
Corporate greed is a growing epidemic throughout the United States that effects people all over the world. The less fortunate citizens often take the brunt of the economic exploitation and manipulation that is allowed within our government. They feel it the most in their wallets and bank accounts as they watch their money get smaller and smaller. Massive corporations now pose a new threat to this growing demographic, and to everyone else, through their spread into the medical field. Illness and disease does not discriminate; the chances that you or someone you know will need to call an ambulance are high. It is even more likely that the first responders will come adorned wearing a uniform with some sort of business logo sewn into their sleeve. Will they provide an adequate level of care? While you’re panicked and fearing for your life, is there a business meeting going on discussing ways to make just a little bit more money off of incidents like the one you’re in? Perhaps one less ambulance was sent out today to save some expenses, delaying precious seconds that you needed to survive. A new approach to the Emergency Medical Service needs to be applied to our culture; one that is injected with some tangible morality. The ability to saves lives should not be tabulated on a calculator or a spreadsheet, but rather thoughtfully, and with the intent of helping those in need, not those with greed.
David Duncan is a History major at California State University, East Bay. He currently works as an EMT in the San Francisco Bay Area.
[1] “EMS White Paper.” EMS White Paper. Accessed September 9, 2015. http://www.emt-resources.com/ems-white-paper.html.
[2] “EMS White Paper.” EMS White Paper. Accessed September 9, 2015. http://www.emt-resources.com/ems-white-paper.html.
[3] “EMS White Paper.” EMS White Paper. Accessed September 9, 2015. http://www.emt-resources.com/ems-white-paper.html.
[4] Rickey Lynn Hendricks. A Model for National Health Care: The History of Kaiser Permanente. New Brunswick, NJ: Rutgers University Press, 1993.
[5] “Appendix B. A Brief History of Managed Care | NCD.gov.” Ncd.gov. Accessed August 14, 2015. https://ncd.gov/publications/2013/20130315/20130513_AppendixB.
[6] “Our History.” Company Portal. Accessed June 22, 2015. https://membership.ruralmetro.com/about-us/our-history/.
[7] “Our History.” Company Portal. Accessed June 22, 2015. https://membership.ruralmetro.com/about-us/our-history/.
[8] Matthew Yglesias. “Tim Geithner Sells Out.” Slate Magazine, 2013. http://www.slate.com/blogs/moneybox/2013/11/18/geitner_goes_to_warburg_pincus_the_inevitable_sellout_everyone_s_been_waiting.html.
[9] Jennifer Daniel, Josh Williams, Ben Protess and Danielle Ivory, This Is Your Life, Brought to You by Public Equity. The New York Times, August 1, 2016. http://www.nytimes.com/interactive/2016/08/02/business/dealbook/this-is-your-life-private-equity.html?_r=1
[10] “AMR Acquiring Rural/Metro Corporation.” Ems1. July 30, 2015. Accessed November 1, 2016. http://www.ems1.com/american-medical-response/articles/3017676-AMR-acquiring-Rural-Metro-corporation/.
[11] Karen De Sà. “Shirakawa’s Decisive Vote in Ambulance Deal Prompts Santa Clara County Scrutiny.” Mercury News. May 18, 2013. http://www.mercurynews.com/ci_23271706/shirakawas-decisive-vote-ambulance-deal-prompts-santa-clara.
[12] Karen De Sà. “Shirakawa’s Decisive Vote in Ambulance Deal Prompts Santa Clara County Scrutiny.” Mercury News. May 18, 2013. http://www.mercurynews.com/ci_23271706/shirakawas-decisive-vote-ambulance-deal-prompts-santa-clara.
[13] Karen De Sà. “Shirakawa’s Decisive Vote in Ambulance Deal Prompts Santa Clara County Scrutiny.” Mercury News. May 18, 2013. http://www.mercurynews.com/ci_23271706/shirakawas-decisive-vote-ambulance-deal-prompts-santa-clara.
[14] Karen De Sà. “Shirakawa’s Decisive Vote in Ambulance Deal Prompts Santa Clara County Scrutiny.” Mercury News. May 18, 2013. http://www.mercurynews.com/ci_23271706/shirakawas-decisive-vote-ambulance-deal-prompts-santa-clara.
[15] Jeff Macdonald. “City Fines Ambulance Firm $230,000.” The San Diego Union-Tribune. October 20, 2015. http://www.sandiegouniontribune.com/news/2015/oct/20/city-fines-ambulance-firm-230000/.
