CAMDEN — A four-town team assembled to review emergency medical services contract proposals for Camden, Hope, Lincolnville and Rockport is recommending the communities sever ties with Camden First Aid Association and instead contract with North East Mobile Health Services. The question is, will voters go for it?

For 77 years, the communities have relied on the same organization for ambulance service. This June, at town meetings, the options are different and now it is up to voters to decide if they want to disengage from a longtime community institution, which is currently suffering severe financial pain, and sign up with a southern Maine-based EMS business that the team has cited for its efficient business model, high-quality service and lower cost to local taxpayers.

Upcoming individual town meetings to discuss the EMS recommendation.

Lincolnville — June 3,  Lincolnville Central School, 6 p.m., at the regularly scheduled selectmen's meeting

Rockport — June 3, Rockport Opera House meeting room, 6 p.m.

Camden — June 4, Washington Street Meeting Room, 6:30 p.m.

Hope — June 11, Hope Corner Fire Station, 7 p.m.

Approximately 75 citizens — primarily selectmen, firefighters and EMS first responders from area communities — gathered in the Camden Opera House to hear a panel of 13 members of an ad hoc review team rationalize their decision. The recommendation was delivered carefully and methodically by Camden Select Board Chairman Martin Cates, backed up by information illuminated on a screen, and in a room laced by an undercurrent of strong emotions. Selectmen were given first priority to ask questions of the panel, approaching the stage. After that, citizens were encouraged to write their questions down and submit them to Peter Gross, who then read them to the team.

"Don't think this is a one and done," said Lincolnville Town Administrator David Kinney, following more than an hour of conversation. "This is not a decision we are going to make and never revisit in the next 100 years. We owe it to everybody in our communities to constantly be evaluating our programs to determine what level of service we want. If the decision is North East, I think we are going to be evaluating EMS against the contract and community expectations. If we go with Camden First Aid, we'd all be involved."

The presentation of how the team reached its decision was followed by the announcement of the decision itself, although most people in the room already knew because news of the team's inclination leaked out from behind closed doors more than two weeks ago.

Although a vote was not taken at the May 29 meeting, the team had apparently conducted a straw vote at one of its earlier May meetings, resulting in 11 to 1 favoring a contract with North East Mobile Health Services. The team listed their reasoning, saying it believed that the Portland-based company is:

• Well-managed

• Has broad expertise in EMS delivery in rural areas

• Has a local presence and an understanding of the Midcoast

• Has highly qualified emergency medical technicians

• The service chief is the former director of Maine EMS

• Has sufficient response times

• Has ambulances based in Rockport and maintains a safe, fuel-efficient fleet

• Maintains an advanced dispatching service

• Has the largest paramedic service in Maine

• Has extensive training and educational programs

• Makes efficient use of personnel

• Is a leader in innovative mobile medical health

• Is active in policy development at federal and state levels

While the review team, consisting of the four town administrators/town managers, their selectmen and one citizen, outlined its criteria for ranking the proposals from Camden First Aid, Delta Ambulance, North East Mobile Heath and Sterling Ambulance (see box below for numbers) to the assembled Wednesday night, they noted that cost was only one factor in the decision-making; however, the package North East is offering taxpayers for two years is substantially lower than CFAA and Delta. For instance, North East is asking Camden for $10,000 this coming year while Camden First Aid has requested $174,000 from the town.

How that largest ambulance service in Maine is able to offer communities the service for the price charged is built on its size and reach: North Eeast Mobile Health Services, with bases in Scarborough, Sanford, Biddeford, Dresden, Topsham and Rockport, handles more than 40,000 calls a year, according to its website.

The privately-owned company serves regions with larger populations, and the business of emergency medical services is largely built these days on transporting people to and from hospitals — calls reimbursable from Medicare and insurance companies.

The changing face of health care, in general, is also forcing smaller community EMS services to rethink their business practices.

“There is a tremendous amount of change going on in EMS, which is why we ended up in this spot," said Rick Petrie, who has been a paramedic for 31 years, and who has been a consultant to the review team for the past month. "It has forced Camden First Aid to take a hard look at delivery of EMS."

Petrie, who is also executive director of Atlantic Partners EMS, a Winslow-based nonprofit with a mission to enhance EMS and public safety through training, collaboration and cooperation among providers, delivered an EMS 101 course.

“We are in people's homes when they are most vulnerable," he said. "We carry drugs. There's laws, there's rules and federal oversight. The days of showing up when the pager goes off are over. They are gone. Mostly because of regulations."

EMS proposals
(Read their complete proposals through the linked PDFs above)

Delta Ambulance Service proposes covering the four towns with a $44 per capita fee that totals $552,640. Breaking down town by town: Camden, $231,396; Hope, $62,832; Lincolnville, $103,400; and Rockport, $155,012.

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Camden First Aid Association is asking the towns to contribute 37 percent of its total $407,000 budget: $174,000 from Camden, $129,000 from Rockport, $77,000 from Lincolnville and $27,000 from Hope.

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North East Mobile Health Services proposes, for the first two years of a contract, charging Camden $10,000; Hope, $1,000; Lincolnville, $5,000; and Rockport, $12,000.

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Sterling Ambulance proposes charging Hope $6,500 annually for two years.

While those regulations complicate business, "they provide safety for EMS and patients," he said. "People were killed for lack of regulation."

Additionally, he said: "Television has not done us any favors. It has created a level of expectation that we have to do really well. EMS is changing not only in Midcoast, but statewide and on a national basis. A lot of it is for good. We are learning how to do our job better, and have better impact on patients."

Petrie said, however, the call volume is a business driver, and an EMS service needs approximately 2,000 billable calls per year to fund one paramedic's salary. This basic economic reality has caused many Maine EMS services to turn to their municipalities to fill the funding void.

 “If you remain reliant on a small ambulance service you rely on subsidies from municipalities you cover,” he said. "Subsidize or diversify. It's no longer reasonable for ambulance services to do stuff for free."

Potential complications

"We've got a lot to consider as we move forward," said Cates, noting that the process, though in a time crunch with the approaching town meetings and the need for the towns to cement their expenditures for the coming year, depends on building public awareness and engagement. “We have an obligation to ferret this process out the best we can with CFAA, but also have responsibility to taxpayer."

He said the review team's effort was thoughtful, diligent and fair-minded, and when the selectmen of each town directed the review team to circulate a request for proposals, “we didn't have a clue of what was out there."

On May 16, the team interviewed the three services (Sterling was interviewed separately by the town of Hope, because it is bidding just on Hope's business).

He said: "We had to consider fiscal responsbility to taxpayers, which is huge. Along with that, and the additional findings, we felt that they [North East} are high quality. One of the big drivers is that the business model is sustainable, and what we felt taxpayers would opt for that price tag. There is a presence in the area. We were looking for leaders in the state, and those opportunities presented themselves."

But, he added that the "process does not end here." 

It is now time for individual towns to weigh in on the recommendation.

"You need to become very involved," he said. "What do you expect in your EMS service?"

After that, comes individual town meetings.

And after that?

"This is an all-depends," said Cates. "We may not be up here for the last time. We don't have the right to depend on all towns being in lockstep. If we don't have our mission clear, we don't have a lot of time to deal with this.”

How did the four towns get to this point? The towns have been discussing EMS since last fall, when Camden First Aid Association informed them that the nonprofit faced a serious financial situation.

Camden First Aid has been providing ambulance service to the towns in one form or another for the past 77 years. While originally it was part of the Camden Fire Department, it became a nonprofit in the 1990s, and most recently was contracting individually with the towns for nominal annual contributions.

But last winter, the select boards heard just how drastic the organization's fiscal outlook had become. On Feb. 27, town officials at a joint meeting were told that Camden First Aid needed $407,000 this coming year to meet budget, up from the $56,000 requested collectively from the four towns last year.

To complicate the issue, the request came just as the four towns were beginning to put their budgets together for their own fiscal year 2013-2014. Those budgets are to be approved at town meetings in June, but the process of considering the EMS price increases began to be debated in March by budget committees and select boards. The Camden-based nonprofit laid out its requests, seeking $174,000 from Camden, $129,000 from Rockport, $77,000 from Lincolnville and $27,000 from Hope.

While Camden First Aid submitted its contribution requests, the town select boards likewise directed their town managers and administrators to circulate a request for proposals from interested EMS providers. Four companies responded: Camden First Aid, Delta Ambulance, North East Mobile Health Services and Sterling Ambulance, the latter of which bid only on Hope. (Currently, Hope is serviced by two EMS providers, Union Ambulance to the west of Alfred Lake Road, and Camden First Aid to the east).

Rockport Interim Town Manager Roger Moody indicated later in the meeting that the recommendation to go with North East is potentially reliant on Camden and Rockport, the two bigger towns, choosing the same route.

“If Camden and Rockport go in different directions, we are going to have some hard conversations, because I don't think the model will be sustainable,” he said.

Lincolnville Selectman Rosey Gerrey asked whether the low price offered by North East would be sustainable.

Lincolnville Selectman Jason Trundy, also a review team member, responded, saying he asked the same question, a concern that was "shared by a lot of us."

After asking North East, the explanation, said Trundy, "turned a lightbulb on."

"North East is in a unique position. North East already has a base in Rockport, that service already has a base number of calls [according to the team, North East makes approximately 500 transports from its Rockport base per year], and the paramedic and crew had time to take on more calls. With a combination of those two things, they would pick up close to 2,000 billable calls. CFAA does not have the numbers."

Camden Selectman John French countered: “CFAA evolved much differently."

But, French added, “It's all about the money. That's what we're talking about at the end of the day. We got a free ride for years. Folks have a tough decision to make."

Later in the meeting, Hope Town Administrator Jon Duke said he had surveyed a few towns that currently contract with North East and said Bowdoinham's 12-year history with the company has cost the town $3,500 and then $3,000 in annual fees.

"For 12 years of service, their contract price had gone down significantly," he said.

While it was not discussed at the meeting, CFAA's current fiscal situation grew from what is commonly accepted as poor business and managerial practices during the late 1990s and first decade of this century. It has a large debt on a relatively new building that was constructed on John Street, requiring approximately $100,000 in annual loan and interest payments.

And though Camden First Aid transports patients, it does not have the volume of billable calls to fund its trucks and paramedics.

In March, Camden First Aid EMS Chief Julia Libby distributed CFAA's 2013 budget to Hope selectmen. That budged totaled $1,096,800 in expenses. Those expenses included a payroll for 10 staff of $477,500, with an additional $86,000 in payroll taxes and benefits. The budget included a 4 percent salary increase for staff.

Expenses also included $60,000 in principal loan payments for the building that Camden First Aid staff and equipment are housed in and another $45,400 in interest payments. The organization has approximately 18 more years to complete payments on its building, she told Hope selectmen.

The budget also built in $100,000 for capital reserve.

Projected revenues included $850,000 in billed ambulance runs and $13,500 in donations.

Bad debt — those unpaid balances Camden First Aid is unable to collect from private patients, who are unable to pay — amounts to $25,000.

The organization has taken steps to collect its bad debt; still, it writes off a certain amount every year.

Other complicating factors that the organization faces includes services it provides but cannot collect on. That includes responding to nursing homes and retirement facilities for situations that can be as minor as helping people who fall down to get back on their feet.

At the May 29 meeting, Camden Selectman Leonard Lookner asked, “With all three of these ambulance services, what guarantee do we have of their financial stability?"

"We feel comfortable with North East," said Camden Town Manager Patricia Finnigan. "They certainly have a very strong financial statement for last several years. Nothing we see in the future that would negatively impact that."

Rockport Selectman William Chapman asked, "What's going to happen to the CFAA building?"

“The building belongs to CFAA,” said French.

Rockport Selectman Geoff Parker said both Delta and North East expressed interest in negotiating with CFAA for the building.

It was noted that if CFAA was no longer being classified as a nonprofit, the town would begin collecting property taxes.

However, it has been stated at previous meetings that CFAA has consistently over the past decade asked Camden for lower contributions to the EMS service than other towns because it was recognized the nonprofit was not paying property taxes; therefore, the organization wanted to give something back to the town in exchange for that.

Another citizen asked if CFAA's building debt was not included in its budget, how would its numbers compare with North East.

There was no such comparison, the team said.

Why did CFAA receive a low rating on its business model, asked another.

Cates responded that CFAA is still recovering from past poor business practices.

"The reality is that recovering from that is tough," he said. "Where are we going? We wanted to find sustainability."

Finnigan said later in the meeting that she wanted to demystify why the review team ranked CFAA's business model as low. 

"It has next to nothing to do with the people who are running CFAA," she said. "It has to do with the reality of being in Midcoast Maine, and all the demographic and economic factors. We were getting to a point to make a decision; that was one of those tipping points. I didn't want people to leave this room without understanding what low means."

What happened to the quasi-municipal idea?

In February, there was initial talk about pursuing the developing CFAA as a quasi-municipal organization, along the lines of the Mid-Coast Solid Waste Corporation, which consists of Camden, Hope, Lincolnville and Rockport.

At the May 29 meeting, however, that discussion had apparently died.

Parker said he was a proponent of the idea.

"It felt like a win-win," he said. "It retains that home feel. That lasted about 10 minutes after we started to get the proposals. With the size of Delta and North East, there are very exciting things they are able to to do. There are forays into paramedic medicine. We like to have our leaders be leaders in larger venues. In much the same way, North East has on their senior management leaders in the national realm. The benefit of professionals, when you take it to the next step, [creates] advantages 10 years down the road."

He added, "I abandoned that idea [quasi-municipal] because it was a stop-gap and it was not to the benefit to the four towns in the long run."

John French said: “I don't share the opinion. CFAA said they were open to discussions. If folks at town meeting decide CFAA is who they want to go with, we have to look at management. CFAA is probably one of the best. I still think we have to wait and see what happens at town meeting.”

Read more

• Camden, Hope, Lincolnville, Rockport 'plowing new turf' with ambulance decisions

• Camden First Aid seeking $407,000 in funding from four-town taxpayers

• Hope gives preliminary nod to Camden First Aid; talks continue with four towns

• Camden, Lincolnville, Rockport to circulate requests for emergency services

Lingering issues

As the voters head to next week's informational meetings about the future of local EMS, they also must consider other first responder functions, such as which departments pick up duties of extrication from vehicles involved in accidents. Currently, CFAA manages an access team, which responds to accidents with hydraulic extrication tools.

Camden Fire Department has in its proposed budget the purchase of more extrication tools, and there has been talk of CFAA's tools going to Lincolnville. Which leaves Rockport wondering where it turns for extrication assistance. Does it contract with Rockland?

At the May 29 meeting, the team said Delta and North East prefer that town fire departments run their own access teams.

That information led to the question of CFAA's high angle/mountain rescue team and its future.

Parker said North East looked "forward to integrating mountain rescue."

And, there was talk about community involvement. Would North East attend and provide supplemental EMS at the U.S. National Toboggan Championships at the Snow Bowl, and at high school events, as CFAA currently does.

French said Delta would charge and North east said there would be some charge. Parker said they would be there at town-sponsored events for 500 or more, and high school for athletic events. Currently CFAA bills a flat fee to provide service to the Toboggan Nationals, which is also serviced by the Snow Bowl Ski Patrol.

"It's unclear as to whether North East would be as generous as Camden [First Aid] has been in the past," he said. "We don't have a totally clear picture of that."

The team did say that North East would stand by for fire rehab [showing up at fires to tend to firefighters' health] when requested, for no charge.

The bottom line is that citizens in the four towns have a lot to think about concerning the future of their EMS. Town meetings are two and three weeks away.

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Editorial Director Lynda Clancy can be reached at lyndaclancy@penbaypilot.com; 706-6657.