The nation's fire service is at war, as it relates to emergency medical services. Not a police action or a conflict but a war. The combatants are The Fire Service vs. The Fire Service, The Fire Service vs. The Public Sector, The Fire Service vs. The Private Sector, and The Fire Service vs. Managed Care.
Five thousand years ago, the Chinese general Sun Tsu wrote The Art of War. His work has been translated and rewritten throughout the years because his basic principles are timeless. Sun Tsu defined war as "the ability to impose our will on the enemy." The weapons of war, he wrote, are intelligence, speed, deception and tactics. If you will accept for a moment that we are at war, do you have the tools within your organization to wage war effectively?
The Fire Service vs. The Fire Service. The fire service is a collection of special-interest groups and we are suffering an identity crisis. We divide ourselves along multiple lines; full-career vs. combination vs. all-volunteer, major metropolitan vs. small city, urban vs. suburban vs. rural.
We also divide relative to who provides EMS vs. the puritans that provide no EMS. Even those departments that provide EMS are divided on how much service is delivered - basic life support (BLS) first response only, advanced life support (ALS) first response, BLS transport, ALS transport and billing vs. non-billing.
What is our role? Since the 1960s, we have effectively reduced the threat of "the red dragon" (fire) by our fire codes, detection systems, suppression systems, fire prevention education and fire-resistive structures. Many of our newer cities have a very low fire problem. Even our older cities are retrofitting their infrastructure and seeing a reduction in their overall fire problem. Is it time for a professional metamorphosis?
Now, before you fire up the tar bucket and get out the bag of feathers, we're not saying we need to reduce the number of traditional fire service resources. The United States continues to lead the industrialized world in deaths by fire. Also, with the advent of plastics, the time-temperature curve has shifted dramatically to the left. Our fires rapidly advance to flashover. We continue to have high life and property hazards that need timely response. However, we do need to look at new ways to serve our communities while we continue to reduce the fire problem. Within the fire service, EMS has become a foster child. We are a part of the family but not a full part.
The Fire Service vs. The Public Sector. Three major cities New York, San Francisco and St. Louis have amalgamated the provision of EMS under the aegis of their fire departments. Reasons include less duplication of existing command, control and communication; efficiency; effectiveness; and, for the policy makers, eventually less costly. All good reasons. However, many within the existing workforce, both fire service and the third service EMS, feel threatened and fearful. Many will become casualties and some will become walking wounded.
It is incumbent upon the fire service to fully recognize the importance of the role EMS plays and minimize the shell-shock effect in the transition for all involved. Embracing EMS as a full fire service partner will go a long way in terms of retooling the organization for future survival and success. Clearly, both organizational structures and cultures can learn from each other with the end result being the emergence of a highly effective and community receptive organization.
The Fire Service vs. The Private Sector. The consolidation of the ambulance industry has created all kinds of chaos. The Chinese definition of chaos is danger and opportunity. There are now only two of the big invested-funded companies left standing (although by the time this goes to print, that may change) Laidlaw/AMR (American Medical Response) and Rural Metro.
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
It is vital to the survival of the fire service and protection of our communities that we understand warfare, or in today's words, "commonly accepted business practices." You see, they are the same. Understanding warfare as defined by Sun Tsu allows us to work at peace from a position of strength. By being constantly vigilant, analyzing intelligence, understanding deceptions and poising our agencies to be agile and speedy, we can overcome the opponents' tactics.
Paul M. Maniscalco is a deputy chief/paramedic with the FDNY Bureau of EMS. He is past president of the National Association of EMTs and is an adjunct faculty member of the National Fire Academy in Emmitsburg, MD. John D. Sinclair is assistant chief/paramedic with Central Pierce Fire & Rescue in Tacoma, WA. He is the International Association of Fire Chiefs (IAFC) EMS Section secretary and an adjunct faculty member of the National Fire Academy.
