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Laidlaw/AMR is a Canadian-held company with its Medical Transportation Division headquarters in Colorado. Prior to the buyout of AMR, Laidlaw/Medtrans had been working on forging alliances with the fire service. AMR, on the other hand, was extremely aggressive in its approach, battling fire departments all over the county. It filed lawsuits against several fire departments for taking away market share and had aggressive media campaigns in many cities across America berating the fire service.
Rural Metro is based in Arizona and is widely known as a private fire service provider. A recent alliance with San Diego Fire Department (at the time of this writing, this alliance is in jeopardy due to a lawsuit filed by AMR) in jointly creating an EMS system brings a promise that it will not compete with any International Association of Fire Fighters (IAFF) affiliated fire department. Good news…or is it?
Sun Tsu would be proud of both of these companies, for they have learned his lessons well. Let us examine the weapons of war that they use.
Intelligence. Both of these companies have several layers of staff personnel working on acquiring data about target communities and departments. In targeted communities, they approach elected officials and community leaders finding a core group of sympathizers. Fire service officials are many times not even aware that one of these companies is in the community until the city council meeting or fire commission meeting. Then they are ambushed about their alleged inefficient management.
These covert operations have been successful in creating panic and anxiety. However, rarely do they convert a publicly held system into a privately held one. Timing is critical; many times, the private company has made its pitch during contract negotiations, thus forcing concessions on the labor unit.
Deception. The San Diego experience is one example. The pledge of not going after fire departments with IAFF-affiliated locals sounds great but there are thousands of non-affiliated fire departments in America. What will it mean to them?
And what happens when a fire department is sued by one of these companies? Before the action is filed, a campaign is initiated to separate out the department being sued. The other departments in the area are told that there is no problem with them, thus taking away allies from the department under attack.
Tactics and speed. These are used to great advantage by the consolidators. Because of their access to vast amounts of capital, they can swoop into a community buy out the local "mom-and pop" ambulance service and establish a beachhead. Then they can create tuck-ins by extending their influence to surrounding communities.
The Fire Service vs. Managed Care. This is the scariest opponent. The wealth accumulated by the managed care players is staggering. They have gone into communities and closed hospitals, capitated physician groups, capitated hospitals, capitated laboratories, and put hundreds of doctors and thousands of nurses out of jobs, all in pursuit of stopping the hemorrhage of money consumed by health care. So, are they managing care or cost? The answer is simple. At this point, they are managing cost.
The fire service must rise to the initiative and form alliances with managed care organizations. We must maintain the public safety net. Two key areas are pivotal to how the fire service can help managed care and keep high-quality care the focus in our communities: "gatekeeping" and "pathway management." Gatekeeping is the process by which a patient is let into the system. Many areas are using a primary care physician, while some areas are using 1-800-Ask-a-Nurse lines. By keeping the fire service involved in the process, 911 can continue to be the proper number of choice. That way, for medical cases that are urgent or critical the information is readily available to responders.
Pathway management is the process of getting the right patient to the right place. Not all patients need to go to an emergency room but in many communities the option to take a patient to a clinic, doctor's office or specialty center or even to treat and release is not available. That is because our systems are dictated by medical directors, most of them emergency room physicians. As managed care penetrates hospitals and physicians, it will force EMS systems to provide for pathway management.
The Peace Process