PORTLAND, Ore. — Multnomah County is fining ambulance provider AMR $513,650 for late ambulance responses during the month of August, escalating a standoff over poor 911 response times in which both parties have blamed each other.
County leaders reviewed AMR's performance in August, finding that American Medical Response ambulance crews were often late in responding to emergencies, triggering penalties as outlined in the county's contract with AMR.
AMR and Multnomah County have sparred over ambulance response struggles for months.
County leaders, including chair Jessica Vega Pederson, have said AMR's performance over the last 18 months has been "unacceptable," leading to concerning waits for emergency care.
"Fines in and of themselves aren't going to solve this problem; I recognize that," Vega Pederson said. "But this is saying, 'AMR, you have the power to fix this problem. We need you to make the investments here in Multnomah County so that our community members get the response times that they deserve and that you're accountable for on the contract.'"
AMR has repeatedly blamed the shortcomings on Multnomah County's rigid two-paramedic requirement for ambulance crews, which the company said has made it difficult to maintain a full staff amid a paramedic shortage.
While other agencies, such as the EMS system in King County, require two paramedics for certain types of calls as part of a tiered system, AMR said Multnomah County is wholly unique in requiring two paramedics for all life-threatening calls.
"AMR operates across 49 states, and AMR Multnomah is the only operation in the entire organization that has such a mandate," a spokesperson said in a statement on Nov. 8.
AMR said a one-paramedic and one-EMT model would help solve the county's ambulance response problems.
"Our neighboring counties have provided excellent service with paramedic/EMT deployments, and Multnomah County would be no different," the spokesperson said. "AMR strongly believes allowing EMTs to work with paramedics is the only viable way to improve response time performance now and for the foreseeable future."
RELATED: 'We could fix this': Multnomah County's 2-paramedic requirement and the clash over 911 solutions
AMR, which also provides ambulance services in Clackamas County and Clark County and recently expanded to Washington County, is required by contract to get to most "Level 3" emergency calls within 8 minutes and meet all compliance standards at least 90% of the time.
The majority of the county's half-million dollar fine — $433,650 — comes from outlier fines, incidents when ambulance crews took more than 13 minutes to respond to a "Code 3" emergency 911 call, or more than 16 minutes and 30 minutes for lower-acuity cases in urban areas (there's more leeway for response times in rural parts of the county).
In total, Multnomah County reports that AMR's performance prompted outlier fines on about 14% of all calls it responded to in August — roughly 1,620 of the 11,577 calls.
"I just think about every single minute past what [AMR] is required to do, for the person waiting for a response, all of the additional stress, anxiety, worry that somebody is experiencing as they're waiting for that help to come," Vega Pederson said.
After receiving an initial report detailing the fines on Oct. 24, AMR opted not to formally appeal the findings, saying, "as an organization we continue to meet with City and County officials to educate everyone on the current state of EMS in Multnomah County."
Vega Pederson said the fine should be paid within the next month and the money will exclusively be used to improve ambulance services in the county. As examples, she listed paramedic and EMT scholarships and retention initiatives, training funds, or other ways to improve ambulance response times.
AMR has said that paramedic staffing shortages have been a primary factor contributing to long waits or altogether unavailable ambulance response.
In the first half of the year, AMR ambulances in Multnomah County were at "Level Zero" — indicating no ambulances were available to respond to a call — on at least 6,300 occasions, per Bureau of Emergency Communications data.
Level Zero cases frequently add strain on fire departments, which provide initial care at the scene of a 911 call but frequently aren't equipped to transport patients to the hospital or provide more significant treatment.
AMR leaders have also listed long wait times at hospital bays as a contributing factor, as paramedic crews need to wait to be released before they can respond to another call.
The county, AMR, and City of Portland attempted to collaborate on ways to improve ambulance service earlier this year.
AMR added "Basic Life Support" crews, made up of two EMTs instead of two paramedics, in order to respond to lower-risk 911 calls and hopefully take pressure off the paramedic crews responding to the bulk of calls in the county.
The parties also changed the 911 dispatch system to better triage different types of emergency calls to different resources.
RELATED: How will Multnomah County fix its ambulance problems? A look at the two big changes to 911 response
Vega Pederson said both changes have had little effect on ambulance response times, so far.
Despite the late arrivals, with fire crews often providing initial treatment on scene, she said the county hasn't noticed any significant changes in health outcomes due to late-arriving ambulances.
"That's something our emergency management folks pay close attention to and so far we haven't seen any marked detriments to health outcomes," Vega Pederson said.
She said the county has not decided if it will fine AMR for lagging performance standards in future months. It will wait to see how this fine is handled before making that decision.
"[A future fine] is something that we have the ability to do. What I would like to see is more investment in some of the ways to address the issues," she said. "[AMR] getting the resources needed to staff at the levels that they need, looking at subcontracting for other providers to help fill in, those are the types of responses I want to see."
Vega Pederson also criticized AMR for expanding into Washington County in August while its response times remained subpar in Multnomah County.
"This is about accountability," she said. "Instead of expanding into other counties, please do what you need to do here and refocus on Multnomah County."
In July, AMR shared a lengthy statement detailing how it planned to address staffing shortages and response times throughout the region.
The company received the fine from Multnomah County on Tuesday afternoon. KGW has asked AMR for an updated response.