BRATTLEBORO — It was almost 11 p.m., about 2{1/2} hours into a three-hour discussion on Sept. 7 about how the town will provide emergency medical services (EMS) in the future, when the conversation focused a beam directly on the town's partnership with previous provider, Rescue Inc.
For a nanosecond, you could hear a pin drop after board member Elizabeth "Liz" McLoughlin, asked the board to direct town staff members to plan to outline a history of the Brattleboro Fire Department's previous relationship with Rescue to include "probable causes and issues" of what is generally seen as a partnership with the town that ended abruptly and full of still-unresolved tensions.
The project to explore options going forward came after a contract dispute last year with Rescue, which had served the town for 56 years.
"I think we have allowed the public to hear Rescue's narrative, and I think it's important, if we truly want the public to understand our decision-making both a year and a half ago and now, [that] we have to have a discussion of what I believe Rescue's relationship with the Brattleboro Fire Department really has been, but I would not let continue," McLoughlin said.
She added that the presentation should include spelling issues out.
"I will no longer accept Rescue's control of this narrative," McLoughlin said.
She prefaced her remarks by saying that transition-of-care issues and inter-organizational coordination are key to her decision-making. They pertain to one medical provider transferring a patient to another at the scene of an emergency and then to a hospital.
Board members Daniel Quipp and Peter Case agreed with McLoughlin, although Quipp first noted that board members have some knowledge "that we can't talk about" on advice of town counsel. He also noted "all kinds of legal pitfalls" potentially and said legal counsel should be sought first.
The Selectboard will decide the future of town EMS at the Tuesday, Sept. 19 board meeting.
Case also thought the information should be brought forth at a separate time from the night when board members will vote.
"I don't feel it's fair that they [the public] find out about the information that we've known about on the same night we have to make the decision," Case said.
Regarding inter-organizational coordination and transition care, Vice-Chair Franz Reichsman said, "we have responsibility not to put employees into a toxic environment."
He said he could support discussion of the issues but cautioned it would not be "productive" if the disclosure were "leading in the direction of justifying past events and settling scores."
Resident Judy Davidson spoke to say that any new discussion of the issues should include both the fire department's view and Rescue's.
She said she believes Rescue recognizes "the intense challenges between the Brattleboro Fire Department and Rescue in the past," and that tensions were exacerbated "without a chance of resolution."
"And that's a tragedy for the organizations and for the town," she said, adding that in its proposal, Rescue offers a structure she believes is aimed to avoid future problems by including case discussion with the medical director and fire department plus mediation if issues arise.
"This, to me, is the rational, reasonable way," Davidson said.
"We are all here trying to the best for the town of Brattleboro […] we're all on the same side," Selectboard Chair Ian Goodnow said.
He was also blunt in his assessment of McLoughlin's proposal.
"I don't think it's a good idea," said Goodnow, an attorney. "I'm not interested in dragging any agency through the mud […] and it's honestly against legal advice that we do that, and you all know that. I don't think it's going to be a productive part of this discussion."
But Goodnow conceded that "it sounds like it's the will of the board, which is fine, and we'll find a way to do it in a way that protects the town as much as it can."
At 11:20 p.m., Quipp, McLoughlin, and Case voted for the information - referred to as "the major tenets" of the relationship's history and rift - to be discussed sometime soon in public. Goodnow and Reichsman voted against that plan.
Two third-party responses
The board had been meeting on Sept. 7 to discuss the possibility of third-party service for emergency medical services (EMS), one of the models stipulated five months ago for exploration, along with a municipal-based service and a contracted service.
A request for proposals (RFP) from third parties brought two responses, each good for 90 days: one from locally based Rescue Inc. and the other from the Springfield, Massachusetts division of American Medical Response (AMR), a company based in Colorado.
"We were very happy to get two really good responses," Town Manager John Potter said. "With this response, we feel we're well on the way to bringing the Selectboard multiple, specific EMS alternatives. Some will be more or less costly to the taxpayer, and some will give greater or lesser ability for the town to manage and set policy, but all of these details will be presented to the board and the public in a transparent and understandable way."
AMR has offered a "dedicated, fully contracted proposal," as Potter put it in a phone conversation on Sept. 11.
That means ambulances and personnel would be dedicated to delivering service solely in Brattleboro and would not rely on municipal personnel as first responders.
Rescue Inc. offered a "shared hybrid model," which would rely on ambulances and personnel working across a larger service area (15 towns) and sharing resources across more towns.
This plan would rely on municipal personnel to some extent. Board members questioned that Rescue anticipated calling on fire department personnel for about 100 calls annually in future versus the 1,300 the department had handled for them in the past.
Assistant Town Manager Patrick Moreland noted AMR's proposal includes one ambulance, while Rescue "typically" stages five ambulances out of the company's Brattleboro garage to serve the towns it covers. The town-run model currently plans for three ambulances.
As to the number of paramedics, AMR's plan is for one to be on duty 24/7 while Rescue would have at least one on 24/7, but typically three to six across the organization's service area. The municipal model plans for two on duty 24/7.
Similarly, AMR's proposal includes two staff members minimum overall on duty while Rescue clearly has more with more area to cover. The town-based model proposes shifts of 10.
Moreland said AMR was not able right away to give a response about guaranteed priority response time "due to a lack of familiarity with the area," but that the company is "more than willing to work with the town" to determine one and "be held to that standard, including a contract with penalty provisions" if the response time is not met.
Rescue officials have estimated a response time, on average, of about 71 seconds longer than the typical fire company response. The municipal model calls for the fire department to answer calls under 8{1/2} minutes, on average.
"The proposal from AMR with one ambulance is insufficient to meet our needs," Quipp said, noting the town currently has three ambulances. "We're a community that needs two ambulances, minimum."
He was told that AMR is working on what the cost would be to provide more ambulances.
Selectboard members also wanted more information from both providers about the availability of mutual aid before deciding on a preferred model, should they choose this direction overall.
McLoughlin said she felt Rescue's proposal was written to "limit the role of the Brattleboro Fire Department," noting that relates to how many firefighters the town employs. She also questioned the anticipated 100 versus 1,300 calls to the fire department for response annually in Rescue's proposal.
"I want to know now what they have in mind so we can plan and we can understand," she said. "If Rescue wants to work for the town of Brattleboro, Rescue needs to work with the town of Brattleboro, and that's a fact that needs to be discussed."
Reichsman said he "imagines" the language around 100 calls is "an attempt" by Rescue to "to deal" with previous issues related to turnovers, handoffs, and whatever else was problematic in the past.
Limiting interactions equals limiting problems, he guessed, adding that he believes a better way is to "deal with the difficulties."
Quipp also worried that dispatchers, which include those in Keene, New Hampshire, may not fully be able to understand the vicissitudes of who is to respond to which calls and that might take critical time to figure out.
"It makes me worry when dispatch gets it wrong," he said. "No disrespect to dispatch."
Bottom lines
When it comes to costs, AMR's proposal is to charge $1.66 million in the first year and $1.94 million in the fifth year, with all revenues passing directly to the town.
Town officials have estimated $703,187 in reimbursement revenue from AMR annually, based "off of previous estimates from Golden Cross," Potter said by phone, adding the numbers were also analyzed for deductions as AMR is not planning to cover all calls and is only recommending one ambulance.
"That's kind of a big challenge in their proposal," he said, calling the equipment proposed by AMR as "significantly less" than what Rescue is proposing or than what is projected in a municipal model.
Rescue anticipates charging about $454,422 for the first year with a 5% annual escalation rate. In their proposal, Rescue keeps all revenue.
One issue, Potter said, is that Rescue "has not been willing to share with the town or anyone what revenues they collect."
"So we have to assume they'd be taking in somewhere around what the town is estimating for the municipal model, which is somewhere between $837,000 and $942,000," he said. "The lower number is derived from actual Golden Cross numbers and the higher is based off of staff analysis and the actual payer mix that we know from the past year from the Golden Cross data."
Overall, said Potter, both proposals had "a few minor things lacking, but we believe there was enough information for the Selectboard to make a decision about which service model they would prefer, if they were to choose a third-party model."
There is also an issue with the RFP requirement that applicants provide audit reports, which Rescue has not yet done. Moreland said the company did provide a link online to the data, but the link hasn't worked, so the town is still working with Rescue to get the information needed.
AMR, he said, provided "a complete independent auditor's report."
Moreland added the audits were requested in the RFP "to fully understand all liabilities a potential provider might have."
Once an RFP includes a particular request, the town cannot then "pick and choose" what information comes back from those who want to do business with the town, he said. Rather, all respondents must provide the requisite information.
Paying attention
Some in attendance alleged that a comparison chart put forth by town staff members was "subjective" and questioned how much public opinion counts.
Potter noted there's no "algorithm to plot the intangibles in each model," but said that staff members tried to organize information to compare apples to apples.
"All the work and incorporation, as best as possible, has been to present to the public decision-making the board generally does in private," McLoughlin said, adding that under the town charter, the ultimate decision is still the Selectboard's to make.
"I wish that people would believe we are taking this very seriously," Reichsman said. "I certainly want to hear from people what their opinions are […] I think we're doing a good job on this, and we're going to come to a good decision."
"We are not making a decision in a vacuum," Case added.
Read complete proposals, comparison charts, and memos regarding the EMS issue at brattleboro.org/emsprojectnews.
This News item by Virginia Ray was written for The Commons.