MOORLACH UPDATE — Ambulance RFP Termination — November 4, 2014

Orange County Health Care Agency (HCA) Director Mark Refowitz called me late Thursday evening to personally inform me that the lengthy RFP (Request for Proposals) process for ambulance services in five zones throughout the County had been terminated. He stated that HCA would rewrite a number of questions in the RFP and reissue it soon. As the state’s Emergency Medical Services Administration (EMSA) had approved the previous RFP questions, it was unclear and vague as to what questions really needed to be modified. I am very disappointed. This has been a lengthy and laborious process and my staff and I have invested significant chunks of time into this endeavor. Now it will be completed next year and our contributions will have been for naught.

From my perspective, the process was fair and transparent. As the Kansas City Royals were losing to the San Francisco Giants in game seven of the World Series, the news of the decision to terminate the RFP flew across the country. Many of the ambulance firms, like AMR, are national. Orange County’s HCA had shaken an industry. Friday morning I bumped into one bidder at my breakfast event and I could not intelligently explain why it had been terminated or for what egregious reasons. Going back to the state with new questions, when the state was fine with the old questions, is awkward and a little difficult to explain. I requested a meeting with Dr. Sam Stratton, but he was tied up that day with a commitment at the University of California, Irvine. I’m hoping he can come by sometime this week for a visit, so I can hear his perspectives. Dr. Stratton has kept me informed throughout this lengthy ordeal and it would be helpful for him to explain why the County’s managers decided to abort. The topic is covered by the Voice of OC below.

There are a couple of holes in the piece that need clarifying. The first is that HCA had delegated the task of approving ambulance contracts to the Orange County Fire Authority. The state’s EMSA ruled that this task could not be delegated, so HCA had to be administer it. I’m not sure if the term “ill-prepared” is a fair one. Shock may be a better euphemism, as a major task and a short timeline was foisted onto HCA. HCA worked closely with EMSA, but EMSA dictated the terms, including that the competitive bidding process makes it possible for only one ambulance service to be the winning bidder for all five zones. It’s nice to have been mentioned in the piece for my long-time efforts to look at different models in how services are provided, but I don’t believe that the Board of Supervisors ever planned on assuming the responsibility of this assignment or, speaking for myself, had designs to exploit it. I allow my managers to manage and they did their best to perform the task in a fair and appropriate manner, based on an extremely short deadline. The EMSA’s preferred methodology was going to guarantee that stronger and larger firms would dominate the field. Consequently, it seemed to me that the only solution for the other firms would be to subterfuge the process with a thousand pin pricks. That strategy looks to have succeeded for this round. I’m sure there may be even more drama after the next round of RFP responses are scored. All to say, I don’t believe it was the Board of Supervisors who politicized this process, thank you very much. Most people understand what happens when someone’s ox gets gored, and this industry blood-fest is no different. (At least the reporter’s mention that no HCA “officials were available” explains the lack of offsetting points of view, i.e., lack of balance in reporting the story.)

For previous UPDATES on this topic, see MOORLACH UPDATE — You’re Being Political — April 9, 2014, MOORLACH UPDATE — Special Attention — March 31, 2014, MOORLACH UPDATE — OCFA Study — March 26, 2014, and MOORLACH UPDATE — ALS/CCW/CCP/AOT — March 5, 2014.

County Ambulance Selection Process Breaks Down


The Orange County Health Care Agency’s process for selecting private ambulance services to support paramedic rescues in 19 cities broke down last week amid questions of favoritism and a lack of transparency.

Records show issues associated with how competing ambulance firms were rated and who conducted proposal reviews prompted the recent cancellation of the near-completed process — which had been dogged by months of controversies, political bickering and intervention by state emergency officials.

No Health Care Agency officials were available for comment, leaving only letters to rejected firms to show what prompted the cancellation.

In one such Oct. 30 letter to AmeriCare MedServices Inc. of Carson, the Health Care Agency’s contracting office wrote: “It has been determined that the solicitation should be further clarified with regard to the scoring process and other items.”

Lacking Experience

Historically, the Orange County Fire Authority conducted the ambulance selection process about every five years — with officials from its partner cities having significant input on which private ambulance firms would service their jurisdictions.

But earlier this year the state Emergency Medical Services Administration, reacting to recent court decisions, ordered that the county take over the process.

The state attempts to maintain tight controls over emergency systems — typically through county health agencies — to ensure patients receive the best care no matter where an incident occurs.

At the time the state announced the change, even health agency officials complained they didn’t have the staff, funds, or experience to handle such a solicitation.

And almost immediately, city and Fire Authority officials in Orange County — as well as the ambulance firms themselves — raised concerns regarding whether Health Care Agency was up to the task.

Not only do Health Care Agency officials lack the necessary experience to oversee such a complicated selection, but putting it under the purview of the county Board of Supervisors injects an element of politics into the process, said some city officials and Fire Authority insiders who have been critical of the process.

Members of the board, particularly supervisor John Moorlach, have made it clear in past statements that they favor the privatization of paramedic services, and some fear the county’s control over the ambulance selection process could push the county down that path.

The current bureaucratic machinations will have no impact on the availability of ambulances to transport patients being treated by Fire Authority paramedics to hospitals throughout the county.

Nonetheless, it didn’t take long for criticisms of the county’s handling of the process to be aired publicly.

Some of the affected cities chimed in even before the selection process was cancelled, calling for an immediate review of what was labeled the “appearance of a failed process.”

In an Oct. 17 letter, Laguna Hills City Manager Bruce E. Channing wrote the county he was “sadly…not sure” the selection process was conducted “in a fair, impartial and transparent manner.”

An Appeals Process

Despite the criticisms and acknowledgements among county officials regarding their inexperience with the process, Orange County did not officially appeal the state’s order — something that both San Diego and Kern counties did, in the first such challenges statewide.

In September, state officials began developing a new appeals framework for such disputes.

State officials say Orange County still could appeal; but the county must make that move, not the independent Fire Authority. There is a direct parallel in San Diego, where the county is appealing on behalf of the city of San Diego, which wants to select a citywide ambulance provider.

If an Orange County appeal were successful, the Fire Authority theoretically could regain control of the ambulance selection process, which is important to its cities who want to maintain more local control.

Fire Authority board members Jeffrey Lalloway of Irvine and David Shawver, a Stanton city councilman, said they didn’t recall any discussions over a possible appeal last winter when their agency lost the solicitation process. Lalloway, who is also an Irvine City Councilman, added he would seek a report on the issue, declaring it important for local control.

The county’s questionable ambulance selection process heightens the need for more communication with local governments, some city officials argue.

In his letter, Laguna Hills’ Channing called for an independent review of the now-failed selection process, which then would go to the county Board of Supervisors.

“Everyone deserves to know if the selection process was or was not tainted by irregularities or improprieties,” Channing wrote.

To select ambulance firms, the Health Care Agency grouped the 19 cities into five zones, with proposals required by July 7. The county reportedly created the five zones because it was more efficient, but city officials immediately saw this as reducing local control. Seven ambulance firms then filed a total of 16 proposals associated for the zones.

On Oct. 9, the Health Care Agency issued its recommendations to the Board of Supervisors — which immediately drew fire from ambulance firms.

These recommendations made Care Ambulance Services Inc. of Orange County the big winner, and Doctor’s Ambulance Service of Laguna Hills the most substantial loser of current market share.

AmeriCare lost its only city here, Villa Park. And McCormick Ambulance of Irvine didn’t get into the region’s coveted paramedic support network.

Protests From Ambulance Firms

Doctor’s, AmeriCare and McCormick all filed protests, which the county declared moot after the process was cancelled. Each protest was grounded in similar complaints, which included:

The state-approved request for proposal framework wasn’t followed; there were irregularities in scoring applicants; and the protest process was fundamentally flawed — ie, a protester had to file within 5 business days, but it could take 10 days to secure records from the county on which the protest would be filed.

Fundamentally, the trio of losers wrote that state emergency laws to ensure a fair and competitive process to select the most qualified provider for life/safety services were violated. They all demanded that the selection results be thrown out and a new process conducted.

Both winners and losers expressed disappointment, citing the public and private cost of another solicitation.

Events surrounding the zone for Placentia and Yorba Linda were cited by some officials as an example of questionable review tactics.

During the review, the Health Care Agency requested that the two eventual highest bidders — Emergency and Care — appear for interview sessions in September before a panel to answer about seven questions.

In final scoring, records show the numerical scores for Care and Emergency Service Inc. of Brea were almost identical, with Emergency Service Inc. rated higher by less than one point.

Dr. Samuel Stratton, the Health Care Agency’s emergency medical services director, attended the panel interviews — as he took a visible role in the selection process.

While it can be argued the county’s emergency medical director could strengthen the review, some observing officials saw the fact that Stratton ultimately reports to the Board of Supervisors as a potential for politicizing the process.

Jim Karras, AmeriCare’s chief operating officer, said he understood Stratton was involved in the review panels, which put the physician in a precarious position.

“Why would he put himself in that situation?” Karras said. “I wouldn’t have done that.”

Both Emergency Services Inc. and Care officials emphatically denied any lobbying or meetings with county supervisors.

Because the county was ill-prepared to undertake the process, the state last summer granted the county a six-month extension to March 2, 2015, to complete the ambulance firm selections.

Already, there is speculation the county won’t make that deadline.

Asked, Care’s Bob Barry said, “I don’t know, it depends on how much of the process they change and how quickly they can get it approved by the state. The county may need another extension.”

Rex Dalton is a San Diego-based journalist who has worked for the San Diego Union-Tribune and the journal Nature. You can reach him directly at rexdalton

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