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• Control. Where EMS is provided by a government agency, elected officials have greater control over how the services are provided. Where EMS is provided by a private entity, elected officials may have less control over how services are provided.
• Financial. There is a cost to providing EMS. Personnel, apparatus, equipment, supplies and training are the most significant expenses incurred when providing EMS. There are also opportunity costs – the costs associated with other duties responders could otherwise be doing if they were not providing EMS. These may include prevention, inspections, training and even responding to other non-EMS emergency calls for service.
There can also be a revenue-generation component to EMS. Many fire-based EMS services, like their private EMS counterparts, charge for services. Changes in reimbursement rules have made collecting fees more challenging and limitations in reimbursements from Medicare and Medicaid limits also impact revenue recovery. However, as long as local officials are willing to charge for EMS, the full cost of the program does not have to be paid by taxpayers. Some opponents to charging for fire-based EMS services may argue that a fee for service is the same as a tax. That is a discussion to be held in local council chambers.
Where fire-based EMS agencies currently do not charge for services, the discussion should be held on the benefit and detriment of billing. Some may argue that charging a fee for a service that previously was free will deter the sick and injured from calling EMS when they really need it. The argument seems plausible, but where agencies have billed for services that has not been their experience. That discussion should compare possibility to probability. Is it possible that a person having a heart attack would not call an ambulance because of the cost? Yes. Is the probability of it happening high? Not likely.
• Competition. Some may argue that public entities should not provide services that could otherwise be provided by private entities. Again, this is a discussion to be held in local council chambers. However, as a city council looks to the services that could be provided by private entities, it should look fairly at all city services through the same lens. There are private entities that can remove snow, mow grass in parks, maintain roadways, fix broken traffic signs and provide recreation programs. There are also private-contract agencies that can provide administration services, finance services and city management services. The slope can be a slippery one.
• Quality of services. Some may argue that the services provided by a fire-based EMS service are of higher quality than those delivered by a private EMS provider. This may be true. It may be false. An independent evaluation of the services can help make that determination. The delivery of public safety should be viewed from a global perspective, a systems approach with interrelated parts. Who is positioned best to provide a service and for what cost? Cost may be viewed not only in the fiscal nature, but also from staffing, time saved or spent, other opportunities created and improved coverage.
We have discussed the importance of defining outcomes when evaluating service delivery. When looking at quality of service, having a desired outcome – i.e. response time, patient to hospital time, patient outcome and system redundancy – is a key ingredient in determining the appropriate provider. Some within the fire department may argue that responders who work for the city are local residents who will show greater compassion for their neighbors than those working for a profit-driven company. Again, the quality can vary widely. There are fire-based EMS systems that are wonderful providers. There are some that are terrible. The same can be said for private systems.