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Sometimes the Government Does it Better

First, three items from my RSS feed:

• Sad news of a head-on collision between a commuter train and a freight train in southern California.
• A letter from San Francisco Paramedic Jonathan Meade (here, at bottom of page) to the Chronicle, which reads in part: "Believe it or not, the inability of the Fire Department to properly manage [medical services] is common knowledge among firefighters and paramedics, doctors and nurses, our supervisors and our mayor."  
• San Francisco has announced that the right to provide the City's Emergency Medical Services will no longer be granted exclusively to the Fire Department. It will now be sold to the lowest bidder.

Mr. Meade is right, but the problem is hardly local to San Francisco.  Most city fire departments are obdurately fire oriented -- they continue to prioritize fire first and emergency medical services (EMS) second, even though EMS accounts for well over two thirds of their daily operations.  That is what produces the weird combination of over- and understaffing that rushes heavy rescue trucks to slips and falls at nursing homes.  But assuming San Francisco has finally decided to call the Fire Department's bluff on the quality of the city's EMS, the move to privatization is hardly a step in the right direction.  It will do little if anything to correct the problems with the city's ambulance services, but it might impair San Francisco's response to natural disasters or mass casualty events like last night's train wreck.  Here is why I think so.

The decision to inject competition into San Francisco's EMS providers comes at the heels of several heavily publicized studies which showed, among other things, that one in four of the city's true emergency 911 callers had to wait more than six and a half minutes for help to arrive. Given that the chances of surviving a sudden cardiac arrest (never mind a gunshot to the face) approach nonexistence after six minutes, San Francisco's response time is unacceptable by every modern standard.

The delays were found to have two primary causes.  The first has to do with San Francisco's mishmash layout, and the way emergency response resources are distributed across the city. One or two emergency responses in the Mission can tax the Fire Department such that a third call might require an ambulance from the Marina, or farther. That scenario is no hypothetical; San Francisco paramedics complain that they run out of ambulances on a near-daily basis. How privatization (where the incentive to staff leanly is even stronger) will address that issue is unclear to me.

The second problem is on the dispatch end.  About 40 percent of San Francisco's 911 calls take over two minutes just to dispatch. That leaves less than four and a half minutes for responders to receive the call, locate the incident on a map, board a vehicle, and drive safely to the scene. If that seems reasonable, try thinking in terms of 270 seconds.  According to the studies, language barriers between callers and dispatchers are the major stumbling block.  Abuse of the 911 system for non-emergencies, and its concomitant clogging of the phone lines, is another significant factor. It seems safe to say that neither of those dispatch efficiency problems will be addressed by privatizing ambulance operations.

In fact, only one thing about the plan does seem certain, at least to me.  It has to do with the reality that only one in three patients pay their ambulance bill. If a private company takes over San Francisco's EMS, it will not be long before that company raises the genuinely legitimate complaint that it is being forced to provide a free taxi service for drunks and the homeless, when it could be providing (and collecting payment from) genuine medical emergencies. Those costs will accumulate, and the burden on the private entity will grow. In order to keep the system rolling, those bills will be picked up by the city (either through cash payments or some form of "health insurance") -- just as they are now, albeit via the Fire Department budget. So, the city will stay on square one when it comes to providing medical services to the indigent, but it will give up the payments from patients or their insurance companies that would offset the cost.  In other words, San Francisco's plan ensures that some private entity will profit from the paying patients, while setting the stage for the city coffers to cover the poor.  This is zero steps forward and one step back by any calculation.

There is a final, more disturbing issue.  Whether that lucky, low-bidding private entity will set aside any of its profit to prepare for an earthquake, bridge collapse, or train wreck, is (to me) the question of the day.  Even if the answer is "yes," will that company do a good job while maintaining its status as the lowest bidder?  Think about that one for a moment; what kind of city would you like to live in?  For all their shortcomings, city fire departments nevertheless operate in the spirit of community planning and public service.  For-profit ambulance companies operate in the spirit of profit. To which set of principles would you prefer your city turn, come the quake, bombing, or commuter accident of the century?

Full post as published by Nuts & Boalts on September 13, 2008 (boomark / email).