Talking Points in the Discussion of Fire and Emergency Medical Service Delivery on San Juan Island Report to the Board of Commissioners Potential changes in emergency service delivery systems Report to the Board of Commissioners Executive Summary ......................................................................................................................... 2 Municipal Corporations ................................................................................................................... 4 Levy Authority ................................................................................................................................. 5 Tax Revenues: .................................................................................................................................. 7 Financial Condition .......................................................................................................................... 8 Facilities ......................................................................................................................................... 10 Inventory ....................................................................................................................................... 11 Emergency Medical Services Billing .............................................................................................. 12 Payroll Costs .................................................................................................................................. 15 Service Delivery ............................................................................................................................. 20 Page 1 Report to the Board of Commissioners Executive Summary This report has been prepared by the San Juan Island Fire Department staff and is intended to present to the San Juan County Fire District #3 critical facts and information relevant to ongoing conversations about the delivery of emergency services. Over twenty years ago fire and emergency medical services were reorganized into two separate agencies. The specifics of that history and the following actions that have brought the two agencies the current situation are, although potentially important learning opportunities, less significant than the mission of identifying the best way forward for emergency service delivery on San Juan Island. San Juan County Public Hospital District #1, (PHD) which operates (DBA) San Juan Island EMS, has proposed that Fire District #3 re-assume the delivery of EMS services. There are a number of challenges to this proposal should it be decided that it is the best path forward. The geography of the two municipal corporations is different. The PHD included all of San Juan Island, Brown, Pearl, Henry, Stuart, Johns, and Spieden Islands. The Fire District includes San Juan Island (exclusive of Friday Harbor), Brown and Pearl Islands. If the fire department takes over providing EMS then the town of Friday Harbor would need to be annexed into the fire district to insure tax funding. The EMS tax revenue collected Henry, Stuart, Johns, and Spieden would be lost. Expanding the fire district to include structure fire protection to the outer islands is currently feasible. The fire district may levy up to $1.50 per thousand assessed value. To increase the current levy by over 100% would require voter approval. That approval would also have to include the recognition that the funds collected for EMS would be part of a permanent levy and not voter approved every six year as is now the case. To put a possible annexation and levy lift on an August ballot (required to collect taxes in the following year would cost up to $30,000. Both agencies are fairly close to balancing current annual revenue and expenditures. The fire department does though, have significantly more funds on hand to address anticipated capital expenditures. For the department those are expenditures are to some extent discretionary, for EMS there are substantial and immediate capital needs. Should the fire district assume responsibility for the provision of EMS services the capital needs of EMS would mean the potential postponement of capital expenditures contemplated by the district. Page 2 Report to the Board of Commissioners A change in operations will direct changes in the funding and use of both fire and EMS facilities. Several organizational models would necessitate an investment by the fire district in expanded facilities to accommodate a move out of the current EMS building. This brings into question the future use of, and financial responsibility for, the building. Existing job descriptions for almost all of the employees involved would be changed. Development of the most effective and efficient organizational model would be imperative based on the limited funds on hand to achieve the transition and on future taxing restrictions. As effectively as these needs may be communicated, payroll and employment changes will come at a significant cost to morale. A new normal would be three to five years in the making. Page 3 Report to the Board of Commissioners Municipal Corporations The borders of San Juan County Public Hospital District #1 (PHD) mirror those of the school district and include San Juan Island, including the town of Friday Harbor (TOFH), Brown, Pearl, Henry, Johns, Stuart, and Spieden Islands. Fire District #3 includes San Juan, Brown, and Pearl Islands and excludes the town of Friday Harbor. San Juan EMS is a function of the PHD, San Juan County Public Hospital District #1. There is not a separate emergency medical service municipal corporation. 2017 Assessed Value Fire District $2,257,123,347 Public Hospital District $2,896,559,316 Town of Friday Harbor $479,523,577 Page 4 Report to the Board of Commissioners Levy Authority To fund the PHD it is authorized by RCW 70.44.060 to levy an initial amount of fifty cents per thousand dollars of assessed value. An additional twenty five cents per thousand dollars of assessed value of the taxable property within the district is also allowed. The PHD, as a special purpose district, is also authorized by WAC 458-19-060 to levy ad valorem taxes for emergency medical services. These taxes are subject to the same $0.50 cent per thousand of assessed valuation as a fire district EMS levy would be. The total amount a public hospital district providing EMS services may assess is $1.25 per thousand dollars of assessed valuation. (RCW 70.44.060) The PHD currently levies forty three cents per thousand dollars of assessed value to fund the Peace Island Medical Center contract, and a separate levy of fifty cents per thousand dollars for Emergency Medical Services funding. There does not appear to be a legal restriction on the PHD’s increasing their primary levy to assist the EMS operation. A fire district may assess up to $1.50 per thousand dollars of assessed value as well as a separate EMS levy. This capacity allows Fire District #2, (Orcas Island Fire) to use a levy rate of $1.07 to fund both fire and EMS expenses. Fire District #4’s, (Lopez Island Fire) levy rate of $0.86 also funds both the fire and EMS operations; neither assesses a separate $0.50 EMS levy. Hospital district, fire district, or EMS levies may be imposed for six years, ten years, or permanently. The hospital district’s and Fire District #3’s (San Juan Island Fire) levies are permanent; the PHD’s EMS levy is imposed for six years. Fire District #2’s, (Orcas Fire) levy is imposed for ten years and Fire District #4’s levy is permanent. If any special purpose district imposes a separate and permanent EMS levy, then those funds must be accounted for separately from any other levies. Separate books are not required for renewable EMS levies, or for expenditures made from a fire districts general levy authority even if the fire district levy is permanent. (RCW 84.52.069) This flexibility might allow the PHD to increase its own levy to raise monies that could be used to fund needed EMS capital expenses. Because of the difference in PHD and fire district boundaries and assessed values, the fire district assessing a $0.50 EMS levy would generate $319,718 less than what is now collected. $239,762 of that amount is based on the assessed value of the TOFH. If a funding mechanism were in place to include the town in a potential fire district EMS service area then the loss would be reduced to $80,046, which represents taxes collected from the outer islands. Page 5 Report to the Board of Commissioners The town would either need to be annexed into the fire district, or a separate EMS fee for service contract would be required. Although it is legally possible to put both an annexation vote and either a fire levy lid lift, or separate EMS levy, on the same ballot it is unclear if this would be successful. Page 6 Report to the Board of Commissioners Tax Revenues: Since 2003 the Fire District has been limited to a 1% increase in its levy amount plus the assessed value of new construction. This same accelerator applies to the current and potential future EMS levies. Earlier budgets represented a 12% increase (2002), the 2001 budget a 0% increase and the 2000 budget a 36% increase. There has been some variability between budget and actual tax revenues. The tables show the budgeted tax amounts, the amounts actually received and the difference between the two. The 2017 receipts are current as of November 30, 2017. Because the EMS levy is based on a fixed amount the tax revenue generated is directly influenced by the assessed value of the PHD. When assessed value declines the amount of revenue generated also declines. This presents operational difficulties in periods of economic contraction. EMS 2017 2016 2015 2014 2013 2012 BUDGETED $1,474,000 $1,072,278 $943,000 $963,142 $1,074,300 $1,271,600 RECEIVED DIFFERENCE $1,413,822 -$60,178 $1,001,967 -$70,311 $971,620 $28,620 $949,560 -$13,582 $994,821 -$79,479 $1,193,673 -$77,972 The revenue from the fire district’s fixed levy is based on the prior levy amount plus 1%, plus the value of any new construction, divided by the assessed value of the district. Thus, a decline in assessed valuation will cause an increase in the levy rate. The revenue generated remains predictable. FIRE 2017 2016 2015 2014 2013 2012 BUDGETED 1,321,700 1,250,000 1,275,000 1,490,540 1,400,000 1,224,000 RECEIVED DIFFERENCE 1,314,093 $-7607 1,316,735 $66,735 1,291,727 $16,727 1,245,714 $-244,826 1,239,253 $-160,747 1,213,970 $-10,020 Page 7 Report to the Board of Commissioners Financial Condition The end of year cash position provides some reflection on the financial health of the organization. The tables below show the end of year balances for various accounts and the 2017 year to date balances. As of November 30, 2017 San Juan EMS has a total of $404,265 on hand. The average monthly expenditures year to date in 2017 are $168,500.00. EMS does not use a reserve account. All cash is held in their general fund. The bond balance represents the amount outstanding on the PHD’s purchase of the EMS building from PIMC. EMS 2017 2016 2015 2014 2013 2012 ENDING BALANCE BONDS GENERAL FUND OUTSTANDING $404,265 $1,694,824 $751,053 $1,756,392 $697,844 $1,840,752 $945,752 $1,897,774 $392,862 $1,953,020 $471,441 $2,000,000 The building at 1079 Spring St. belongs to the PDH. The bond issued to pay for the building was drawn against the PHD doing business as San Juan Island Emergency Medical Services. The EMS division of the PHD pays the $9,694 per month principle and interest payment. The original bond was issued by the PHD (D/B/A San Juan Island Emergency Medical Services / Island Air Ambulance) in the amount of $2 million. It was used to fund the purchase of the .7 ac of land and the building which had been completed by Peace Island Medical Center. The original payment schedule was described as “Installment” with an agreement to adjust the interest rate every 10 years. In February of 2016 the amortization schedule, which runs through November 2022, was amended to remove Island Air Ambulance and lists the PHD dba: San Juan Island EMS as the borrower and indicates a “Balloon” repayment schedule. This modified amortization schedule runs through November 2022 and terminates with a $1,362,289 balance due. Due to difficulties with a former EMS billing contractor and other influencing factors, the PHD amassed an accounts receivable balance of over $4 million. The PHD has since written off as uncollectable a significant portion of that amount. Page 8 Report to the Board of Commissioners EMS is holding aside approximately $25,000 to address potential fines resulting from the CID or Medicaid fraud investigation. A meeting is scheduled for February at which time the State will present its case and negotiations will begin on the level of fines and penalties. The situation may be cleared in six to nine months, but the final penalties are unknown. Larger ongoing or anticipated expenditures for EMS include the continued bond payment to Islanders Bank and significant capital expenditures which may soon be required. These are detailed under “Inventory” later in this document. The fire district maintains a general fund account as well as a reserve account, which is dedicated by policy to larger capital expenditures. Funds received from the sale of equipment are deposited in the reserve account, (i.e. the sale of the Almar fire boat). The separate Length of Service Award Program (LOSAP) account is dedicated to funding the part time firefighters’ service recognition program. The Capital Account is currently used as a suspense account for the payment of the Key Bank loan which was used to purchase the new engines. The Bond Balance represents the balance of the Key Bank loan. ENDING BALANCE FIRE 2017 2016 2015 2014 2013 2012 GENERAL FUND $1,180,431 $1,147,299 $997,390 $889,603 $919,325 $540,686 RESERVE ACCT. $205,944 $204,498 $156,350 $156,134 $156,001 $155,768 LOSAP $237,652 $223,960 $211,101 $210,866 $210,721 $210,468 CAPITAL ACCT. $24,053 $24,053 $24,052 $221,953 -$167,443 $0 BOND BALANCE $1,477,762 $1,656,516 $1,915,483 $2,384,849 $2,622,385 $0 As of November 30, 2017 the fire district has a total of $1,671,207 in cash and investments on hand. The average monthly expenditures year to date in 2017 are $152,000.00. Larger ongoing expenses for the fire district include monthly $26,000 payments to Key Bank. Significant capital expenditures soon to be required are detailed under “Inventory” later in this document. Page 9 Facilities Report to the Board of Commissioners The EMS building includes two offices with multiple work stations, kitchen, classroom, day room, three bunk rooms and laundry shower facilities, as well as two apparatus bays, and various equipment and storage rooms. There is limited exhaust extraction from the bays which exposes equipment and drug storage, as well as the EMTs work area to potential carcinogens. There is limited parking in the lot with some on street parking north of the building. The mortgage and maintenance cost of the EMS building would make its continued use as a separate facility of a joint operation problematic. Its continued use would also serve to psychologically silo the EMS operation from the fire operations. Station 31 was at capacity the day we moved in. To accommodate EMS operations the maintenance function would have to be moved from the Sta. 31 bays. This may be as simple as adding on to the north end of the building, or as involved as acquiring land and building a standalone facility. If the stand alone facility is desired it would have to be very near to Station 31 to facilitate the staff’s timely participation in responses. An addition to Station 31 would necessitate the acquisition of land for use as a drill ground. A letter has been sent to the adjoining property owner to the north to inquire about the availability of that land. That land is currently assessed at $507,400. If fire and EMS operations are brought into one agency then a resident firefighter / EMT program would be a future option. By initially using Station 31 (Headquarters), and then finishing Sta. 33 (Bailer Hill Rd.) and rebuilding Sta. 35, (Roche Harbor) we would be able to recruit young firefighters from off island who are interested in a career in firefighting. By offering living quarters, training, and experience to off island recruits we might increase staffing and reduce reaction and response times in outlying areas. For this program to work we would also need to return to IFSAC, (International Fire Service Accreditation Congress) certification which would be offered in conjunction with WA EMT-B training and national registry EMS certification. Station enhancements may range from $200,000.00 to $700,000.00. Page 10 Inventory Report to the Board of Commissioners EMS inventory items not classified and “small and attractive” include: # 8 3 1 3 4 3 2 Item Life Pack Defibrillator Glydescope Intubation Devices PTV Ventilator Stryker Power Cots Ambulances Medic Chase Cars Additional Vehicles Replacement Cost $25,000 $15,000 $18,000 $25,000 $175,000 $35,000 $25,000 Age Obsolete at end of life 5%-100% life left 20%-90% life left 25%-60% life left Within the next five years a substantial amount of EMS inventory is scheduled to be replaced. This includes defibrillators with a total replacement cost of $200,000, power cots with a total replacement cost of $75,000, a medic chase car with a replacement cost of $35,000, 2 ambulances with a total replacement cost of $350,000. The total scheduled replacement costs exceed $660,000. Larger expenditures on the five year horizon for fire include the refurbishment/replacement of one tender (up to $200,000), replacement of Engine 371, (Brown Island), at $175,000, replacement of self-contained breathing apparatus (SCBAs) ($411,000), potential land acquisitions at Sta. 36, and land for a training or a maintenance facility. The replacement of R314 is also a long term consideration. Page 11 Report to the Board of Commissioners Emergency Medical Services Billing Because EMS has the additional source of revenue through billing it is presented separately from the general financial topic. Billing is allowed according to the level of service provided. The most common levels include; Basic Life Support (BLS) non-emergency, Basic Life Support (BLS) emergency, Advanced Life Support, (ALS) non-emergency and Advanced Life Support (ALS) emergency. The initial classification of the call is performed by the paramedic at the time their report is written. This classification is reviewed by the billing company who either proceeds with billing or contacts the EMS administrative assistant for clarification. Systems Design, the billing contractor currently used by San Juan EMS, will make three attempts at collection of amounts not reimbursed by insurance or the Center for Medicare and Medicaid Services (CMS). After those attempts they review the billing with the administration to decide if the remaining balance is collectable or should be written off. Systems Design charges approximately $22.00 per EMS call billed. Medicare (CMS) pays a base rate which is then adjusted according to the complexity of the call and our rural location. The chart below shows the SJI EMS rate billed and the allowed Medicare rate for the most common call types. Since 2004 the CMS rate has included a bonus payment. The Medicare Ambulance Relief Bill was set to expire in 2008 but has been extended in one year increments since then. As of mid-January this extension has not occurred. This will result in a net change of 0.9% in urban areas, -1.9% in rural areas and -21.5% in super rural areas. There are a number of other considerations in reviewing the EMS billing process. An original invoice is generated by the billing company and sent to the patient’s insurer or to the patient if they are uninsured. The original bill is reduced to either the Medicare/Medicaid rate paid or to the amount an insurance company will pay for that service. Medicare Discount Medicare Payment % Received from Medicare BLS NE $1,350.00 $1,118.96 $231.04 17.10% BLS E $1,350.00 $980.33 $369.67 27.40% ALS 1 NE $1,350.00 $1,072.75 $277.25 20.50% ALS 1 E $1,350.00 $438.98 32.50% Call Classification Billed $911.02 Page 12 Report to the Board of Commissioners The resulting write down is noted as “disallowed” on the chart below. The co-pay amount, or that portion that the patient would normally be held responsible for, is written off for residents of the taxing district. This is represented by the “Levy’ portion chart below. Finally any payments received are posted. The consideration provided to local residents most dramatically affects the nonemergency BLS billing. 27% of that amount is written off (included “levy” with payments on the EMS billing company reports) Emergency calls, both BLS and ALS are discounted an average of 7% for residents. Anecdotally, the collection percentages shown below are considered to be pretty good in the emergency service industry. Currently the billing is tracking the amounts collected, written down, and written off, after seven months past the billing date. Due to a slow pace of payment invoices are considered collectable for at least six months. Amount Billed BLS NE BLS E ALS 1 NE ALS 1 E $1,350.00 $1,350.00 $1,350.00 $1,350.00 Average Average Amount Revenue Collected by Call Type 17.20% $232.20 28.30% $382.05 17.40% $234.90 21.40% $288.90 Page 13 Report to the Board of Commissioners WA Health Care Authority (HCA) is implementing a Medicaid based program that will enhance the amount collectable for Medicaid transports. The Ground Emergency Medical Transport (GEMT) program may provide an approximately 50% increase in Medicaid payments for BLS non-emergency billings. This reimbursement may available retroactivity for some specific period. The program has been in development for several years and may be online some time in 2018. Page 14 Payroll Costs Report to the Board of Commissioners Payroll, both career and part time or volunteer stipend makes up a significant part of both organizations operating costs. Information presented below includes information from EMS (San Juan), Fire 2 (Orcas Island), Fire 3 (San Juan), and Fire 4 (Lopez). Costs presented here are before various benefits including health and dental insurance, deferred compensation, life insurance and health reimbursement account contributions. The Chief and Admin chart includes the chief’s salary and the anticipated hourly wage of any administrative assistant or officer. The Fire 3 numbers are slightly inflated in anticipation of the administrative officers’ participation in incident management, the pass through of which inflates overtime costs. CHIEF & ADMIN BASE WAGE COSTS 2016 2017 2018 EMS $188,522 $172,700 $168,900 FIRE 2 $142,501 $256,535 FIRE 3 $207,000 $215,000 $230,150 FIRE 4 $127,448 $130,650 Career staff positions at EMS include public education specialist, paramedics, and career EMTs. The career staff positions at Fire include the assistant chief and the maintenance staff. STAFF PERSONNEL BASE WAGE COSTS 2016 2017 2018 EMS $521,284 $541,734 $570,200 FIRE 2* $304,825 $547,513 FIRE 3 $396,000 $448,987 $477,120 FIRE 4 $242,450 $256,000 Budgeted base wages for all career staff. ADMIN & CAREER STAFF BASE WAGE COSTS 2016 2017 2018 EMS $709,836 $714,434 $739,100 FIRE 2* $447,326 $804,048 FIRE 3 $603,000 $663,987 $707,270 FIRE 4 $369,898 $386,650 • Fire 2’s Eden financial report did not include a committed budget. Values used are Eden reported actuals. Page 15 Report to the Board of Commissioners Part time wages vary between the agencies. The EMTs are paid a $20.00 stipend for each daytime call, $25.00 for each nighttime call, and $30.00 for each training event. There are several other enhancements for performing rig checks, scheduled transports, etc. Part time fire personnel are paid a base wage of $15.00 per hour with enhancements for rank, certification, and length of service. Details of the various stipends and wage enhancements are shown below. Fire has not historically spent the fully budgeted amount but changes in payroll policy and members’ level of participation will bring us closer to our historically budgeted amount. BUDGETED PART TIME STAFF PERSONNEL COSTS 2016 2017 2018 EMS $176,093 $139,000 $148,000 FIRE $300,000 $300,000 $300,000 Total budgeted personnel costs including administration, career and part time or volunteer members. EMS FIRE 2016 $1,278,675 $1,091,800 2017 $1,138,580 $963,387 2018 $1,155,596 $1,007,270 Depending on the operational model developed there may be changes in payroll costs. The chart below shows firefighter/EMT and firefighter/paramedic wages in 4 fire districts that have a similar assessed value to the combined fire district and town of Friday Harbor. Island 1 Kitsap 10 Kittitas 2 Spokane 8 FF/EMT FF/PARA MIN MAX MIN MAX $64,557 $80,697 $73,434 $89,573 60% $77,862 70% $85,648 $57,968 $72,460 $35,214 $79,706 $55,726 $64,504 $61,297 $70,954 Page 16 Report to the Board of Commissioners The current San Juan EMS medic contract calls for rates range from $76,786 to $110,000 before benefits. This contract was recently renewed for one year. The 2018 budget for base wages for two career EMTs is $104,000.00. These individuals serve as Operations Director and Logistics Coordinator as well as shift EMTs. According to the Bureau of Labor Statistics, the mean hourly EMT wage is $17.36 and the median $15.71. Bellingham is among the highest paying metropolitan areas with a mean EMT/Paramedic wage of $29.08. Commercial HR sites list the average Seattle EMT-B wage at $14.74 per hour. The San Juan EMS career EMT-Bs have significant job duties beyond medical care. One of the positions fills the role of Director of Operations and the other serves as the agency’s Logistics Director. When viewed through the lens of the WA Fire Chiefs’ wage survey the fire district pay rates are in the upper portion of the lower half, of similar sized participating agencies. Fire district part time and EMS volunteer members are currently compensated differently. Firefighters are paid an hourly wage and are categorized as part time employees. EMTs are classified as volunteers receiving a stipend. EMS is currently not able to generate a report on the number of hours each volunteer contributes to training and responses. The EMS administration has stated that the current EMS budget does not allow the organization to match the fire districts wages. Fire District part time employees: FF Training & Response Officer Training & Response IFSAC FF1 IFSAC FF2 Each 5 years membership Back up duty officer Sleeper or Standby per $15.00 hour per $18.00 hour per $0.50 hour per $0.50 hour per $0.50 hour per $2.00 hour per $25.00 shift Page 17 Report to the Board of Commissioners Page 18 EMS volunteers: Report to the Board of Commissioners Day Response Night Response Rig Check Marine Response Training Lieutenant Scheduled Transport Coordinator Ferry Transport Overnight on mainland 6 Hour Shift Standby 8 Hour Shift Standby $20 $25 $20 $75 $30 $100 $50 $150 $100 $15 $80 per event per event per event per event per event per month per month per event per event per event per event Anecdotally, an aid call from start to finish averages two hours; simple transports are closer to one hour. Moving the EMTs to an hourly wage would have an additional financial impact but in comparison to the many other possible financial complications it is less significant. Page 19 Report to the Board of Commissioners Service Delivery 69 of the EMS licensed fire departments in WA run ALS, 259 run BLS only. In many areas ALS service is provided by a local PHD or an independent EMS district. The isolation of our County’s individual districts had forced them to provide their own ALS services. It is unclear if retaining ALS only services would serve the PHD’s goals. Geography and cultural differences make a countywide EMS district, which might provide ALS trained paramedics to each island, a difficult proposition. Schedules Currently the San Juan paramedics work thirteen 24-hour shifts per month. This number is higher than might be worked “on the mainland”, but the local medics are able to respond for home. The do not stay at the station while on shift. The EMT-Bs are rostered into three teams. Each team is scheduled to cover days one week, nights the next week, and has the third week “off”. Members of each team are asked to sign up for 12, 6, or 3 hour shifts during their group’s assigned schedule. The goal is to have at least two, but not more than four EMTs assigned at all times. In an effort to increase staff productivity EMS tried an experiment of not having career EMTs respond during the day. The cultural and operational costs appear to have outweighed the intended productivity gains. The fire district has one chief officer on duty as the primary duty officer, and a second member schedule as a backup, or shadow duty officer. The chief officer’s shift runs 24/7 one week and then one week off. The backup duty shift runs on the same schedule and is shared among the mid-level officers. The primary duty responsibility has historically been seen as part of the salaried FLSA exempt position. The 2018 budget does allow funds for further consideration of this position. The shadow duty officer position is paid a $2.00 per hour standby wage and the member’s regular wage guaranteed for one hour in the event of a call. Rank and file firefighters are not scheduled but are expected to respond as needed whenever available. Standards of Cover The NFPA standards for staffed stations call for a reaction time of 90 seconds for fire responses and 60 seconds for EMS responses to occur 90% of the time. NFPA 1720 prescribes similar standards of cover for both fire and EMS responses. For the urban area (>1,000 per square mile) resources should be on scene within 9 minutes Page 20 Report to the Board of Commissioners 90% of the time. For the rural area of the island (<500 per square mile) resources should be on scene within 14 minutes 80% of the time. EMS call volume fell by nearly 33% with the opening of PIMC; they have now stabilized with a reduction on 4% for the year of 2017. Fire call numbers increased by 37% over the past three years. # of calls San Juan Fire San Juan EMS 2013 193 900 2014 235 1021 2015 307 930 2016 293 1198 2017 321 1008 With patients self-presenting at the PIMC emergency room, the bread and butter of EMS has changed. Simple transports of the Island Air crew to the hospital and back to the hanger represents approximately 20%-30% of the current call volume. If Island Air decides to purchase and operate an ambulance, a reliable revenue source would be lost. The PHD includes Henry, Stuart, Johns, and Spieden Islands. The North Region Emergency Medical Services and Trauma Council Strategic Plan dated May 2016 includes the statement that all of the other outer islands are under the Sheriff’s jurisdiction but that ALS services are provided to each of them through a contract between the Sheriff and EMS. The current EMS Chief was not aware of such a contract. An agreement does exist for EMS to assess individuals for fitness to be held in detention and to treat individuals being held at the Sheriff’s office. A onetime, during the five year life of the contract, credit of $10,000.00 was applied to the 2015 dispatch fee. Although this represents a $2,000.00 per year “credit”, the full amount was absorbed by EMS in 2015. The frequency of calls to the jail should be reviewed in anticipation of the 2020 renegotiation of the dispatch contract. Page 21