MULTNOMAH COUNTY, Ore. — An unlikely partnership between two longtime rivals could help improve emergency medical services in the Portland area — but it's not being utilized in Multnomah County, where it's arguably needed the most.
"Ambulance service over the years has been built on competition, but things have changed significantly," said Metro West Ambulance Vice President Larry Boxman. "The environment has changed, conditions have changed, and if we as health care and EMS providers don't respond to those changing times, we're not doing our job."
American Medical Response, or AMR, is now the primary ambulance provider in the greater Portland metro area — contracted in Multnomah County, Clackamas County, Washington County and Clark County.
AMR has frequently failed to meet ambulance response time targets in each county, highlighted in a data analysis recently published by KGW.
In August, Washington County switched from Metro West to AMR. The move pushed Metro West to primarily non-emergency transport, such as taking patients from the hospital to their homes or dialysis treatment.
Now, just five months later, Metro West is back in the 911 arena in Washington County because AMR asked for help.
"It doesn't solve all the problems but it's a piece of a solution, so it's helping," said Randy Lauer, AMR vice president for the region.
The two companies, which for years have competed for county contracts, are now working together to solve paramedic and EMT staffing shortages and late response times.
"Their level of cooperation and their willingness to support and recognize this crisis has been very helpful and we're very thankful," Lauer said of Metro West.
Currently, Metro West runs one ambulance unit in Clackamas County. The subcontracting method is being used more heavily in Washington County.
When AMR gets down to three or fewer available ambulances in the county, the company calls in Metro West to take 911 calls.
Boxman said Metro West crews were activated 162 times in its first month of subcontracting from early December to early January. He said it could be a sustainable model moving forward.
"Having two providers in the system really seems to be the key," Boxman said. "That way if one provider runs into staffing problems or any other problems, it doesn't have to carry the weight of everything."
Lauer said Washington County’s staffing levels and response times are now improving, so it's uncertain how frequently the subcontracting model will be used in the months ahead.
However, he admitted that Multnomah County has a more serious problem.
Multnomah County officials and AMR have clashed for months over how to solve its ambulance response problem.
The county fined AMR $513,650 for one month of late responses. AMR insists it can’t fix the staffing shortage and late response times as long as the county requires two paramedics on each ambulance — a requirement not found in neighboring counties.
Multnomah County Chair Jessica Vega Pederson has repeatedly listed subcontracting as a potential solution — in the county's fine explanation, in a letter to East County mayors, and elsewhere.
Lauer said he’d like to subcontract in Multnomah County, but AMR believes the current ambulance service plan with Multnomah County only allows the company to subcontract with fire departments.
The section of the plan reads: "The contracted provider agency may subcontract a limited amount of required ambulance services to established fire departments or districts that provide medical first response within the [ambulance service area]."
Lauer said AMR has checked with local fire agencies who told him that they don't have the staff to help. The ambulance service plan doesn't explicitly say anything about other private ambulance providers, such as Metro West.
In contrast, Vega Pederson told KGW she disagrees with AMR's reading of the contract that it can only partner with fire agencies, saying in a statement:
"I am in full support of Multnomah County and AMR exploring and evaluating any subcontracting, mutual aid, or partnership that could assist in increasing AMR’s performance within the County. The current contract does not preclude contracting with other providers."
Lauer said if the county changed the contract to say AMR can work with other private providers, AMR would do that.
"Absolutely, yeah, anything that will help put even one more ambulance on the street every day," Lauer said. "We're looking for wins as small as that, just one more ambulance. We’d like to have 20 more but every one helps."
So, both AMR and the county claim they're interested in expanding ambulance subcontracting, but neither have taken the steps to do so.
Lauer said subcontracting with a private provider could offer limited help, but insists that the only way to significantly improve response times is to pause the county's two-paramedic requirement.
Multnomah County health leaders told KGW that AMR has yet to present any type of subcontracting proposal to improve ambulance staffing in the county.
Meanwhile, from Metro West's offices in Hillsboro, Boxman told KGW that Metro West would be happy to send additional ambulance crews to Multnomah County.
"Yes we would, if we were asked, we would do whatever we can to help," Boxman said.
Naturally, Metro West has the most to gain through expanded subcontracting (and revenue streams) throughout the area. However, with industry staffing shortages and frequent cases of unavailable ambulances leading to increased public safety risk, Boxman said he believes a two-provider system is the way forward.
"We could take our resources combined with AMR's resources and provide a much better level of coverage than we can as any single provider," he said. "The ultimate benefit is to the community members because they don't have to worry, is an ambulance going to be available (when you need it)."
If Metro West were to subcontract in Multnomah County, it's unclear if the company would need to comply with the county's two-paramedic per ambulance requirement. Metro West normally staffs Advanced Life Support ambulances with one paramedic and one EMT.
While Multnomah County insists that two paramedics per ambulance provide better clinical care, county EMS leaders released revised protocols on November 30 that seem to allow for some flexibility.
Titled "Transport by Fire Department Apparatus" and intended to address what to do during "extraordinary circumstances which overwhelm the emergency transport system," Multnomah County EMS listed the following preference or transport options:
- AMR 911 ambulance staffed by two paramedics - (the standard 911 transport mode)
- Fire Department licensed ambulance - with at least one paramedic
- Mutual aid by a licensed 911 ambulance from neighboring County - with at least one paramedic
- AMR BLS ambulance - with at least one paramedic
- Fire apparatus - with at least one paramedic
- Any of the above options with a lower level EMS provider in place of the one paramedic
- Any of the above options with no licensed person to care for the patient during transport
Metro West would seemingly fall under Category 3, which only requires one paramedic. The standing order was issued for "single responses" that meet the criteria, not for authorization for a "continuous uninterrupted duration of time."
However, with the frequency of "Level Zero" cases in the county, ambulance availability in Multnomah County is often near-zero, which could warrant emergency status.
If AMR Multnomah County were to adopt a similar "surge" model to Washington County, where Metro West is only called in when AMR ambulances reach dangerously low staffing levels, Metro West could be able to respond with its usual staffing of one paramedic and one EMT.