2017A-EMS-0006-DHS VOLUME 4 12/15/2016 833
1 BEFORE THE OFFICE OF ADMINISTRATIVE HEARINGS
2 IN THE MATTER OF: )
3 ) Hellsgate Fire District ) No. 2017A-EMS-0006-DHS
4 dba Rim Country Fire and ) Medical Service, ) (EMS No. 4163)
5 ) Applicant. )
6 ____________________________)
7
8 At: Phoenix, Arizona
9 Date: December 15, 2016
10
11
12
13 REPORTER'S TRANSCRIPT OF PROCEEDINGS
14
15 VOLUME 4 (Pages 833 through 1116)
16
17
18
19 COASH & COASH, INC.
20 Court Reporting, Video & Videoconferencing 1802 N. 7th Street, Phoenix, AZ 85006
21 602-258-1440 [email protected]
22 Prepared By: JODY L. LENSCHOW, RMR, CRR
23 Certified Reporter Certificate No. 50192
24
25
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 834
1 INDEX TO EXAMINATIONS
2 WITNESS PAGE
3 EDWARD RACHT, M.D.
4 DIRECT EXAMINATION BY MS. FICKBOHM 841 CROSS-EXAMINATION BY MR. RAY 895
5 CROSS-EXAMINATION BY MR. MEYERSON 902 REDIRECT EXAMINATION BY MS. FICKBOHM 931
6 RECROSS-EXAMINATION BY MR. MEYERSON 935
7 DOUG JONES
8 DIRECT EXAMINATION BY MS. FICKBOHM 936
9 CROSS-EXAMINATION BY MR. RAY 958 CROSS-EXAMINATION BY MR. MEYERSON 970
10 REDIRECT EXAMINATION BY MS. FICKBOHM 993 EXAMINATION BY ALJ SHEDDEN 994
11 RECROSS-EXAMINATION BY MR. MEYERSON 996
12 ALAN MAGUIRE
13 DIRECT EXAMINATION BY MS. FICKBOHM 998
14 CROSS-EXAMINATION BY MR. MEYERSON 1008
15 RICHARD BARTUS
16 DIRECT EXAMINATION BY MS. FICKBOHM 1013
17 CROSS-EXAMINATION BY MR. RAY 1051 CROSS-EXAMINATION BY MR. MEYERSON 1056
18 REDIRECT EXAMINATION BY MS. FICKBOHM 1070
19 JIM ROEDER
20 DIRECT EXAMINATION BY MS. FICKBOHM 1073
21 CROSS-EXAMINATION BY MR. MEYERSON 1084
22 JOHN VALENTINE
23 DIRECT EXAMINATION BY MS. FICKBOHM 1086
24
25
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1 INDEX TO EXHIBITS
2 NO. DESCRIPTION OFFERED ADMITTED
3 Exhibit LLA-3a "Prevalence of 878 878 Hyperventilation in
4 Intubated Patients with Closed Head
5 Injuries in the Prehospital Setting"
6 Exhibit LLA-3aa Chest Pain - Pain 877 877
7 Decrease Chart
8 Exhibit LLA-3cc AMR World CPR Challenge 876 876 Summary (2016 results)
9 Exhibit LLA-3dd "Do EMS Providers 868 868
10 Accurately Ascertain Anticoagulant and
11 Antiplatelet Use in Older Adults
12 with Head Trauma?"
13 Exhibit LLA-3ee AMR Infographics (2016) 861 861
14 Exhibit LLA-3ff CDC-SOP for patient 865 865 handoffs (ground
15 ambulance)
16 Exhibit LLA-3gg CDC-SOP for patient 866 866 handoffs (air to
17 ground ambulance)
18 Exhibit LLA-3j 2013 Poster, Mobile 855 855 Integrated Healthcare
19 Practice
20 Exhibit LLA-3k "Mobile Integrated 856 856 Healthcare Practice:
21 A Healthcare Delivery Strategy to
22 Improve Access, Outcomes, and Value"
23 Exhibit LLA-3l "EMS at the Healthcare 858 858
24 Table"
25
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1 INDEX TO EXHIBITS CONTINUED
2 NO. DESCRIPTION OFFERED ADMITTED
3 Exhibit LLA-3n "An Evidence-Based 881 881 Prehospital Guideline
4 for External Hemorrhage Control"
5 Exhibit LLA-3p Medtronic 858 858
6 Philanthropy's "Principles for
7 Establishing a Mobile Integrated Healthcare
8 Practice"
9 Exhibit LLA-3r PIM & PIT description 864 865
10 Exhibit LLA-3u What Really Matters - 864 864 Bourn article
11 Exhibit LLA-3w 2013 SCA Facts AMR 871 871
12 (2012 Data)
13 Exhibit LLA-3x 2014 SCA Facts AMR 874 874 (2013 Data)
14 Exhibit LLA-3y 2015 SCA Facts AMR 875 875
15 (2014 Data)
16 Exhibit LLA-3z 2016 SCA Facts AMR 875 875 (2015 Data)
17 Exhibit LLA-5c ADHS's Director's 1093 1093
18 Final Decision dated 01-26-2016
19 Exhibit LLA-13a Doug Jones Resume 940 940
20 Exhibit LLA-13b Rich Bartus Resumé 1019 1019
21 Exhibit LLA-13e Dr. Racht Resumé 849 849
22 Exhibit LLA-13g Jim Roeder Resumé 1075 1075
23 Exhibit LLA-13h John Valentine Resumé 1091 1091
24 Exhibit LLA-13k Alan Maguire Resumé 1001 1001
25
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1 INDEX TO EXHIBITS CONTINUED
2 NO. DESCRIPTION OFFERED ADMITTED
3 Exhibit LLA-14 CON 58 and City of 1077 1078 Payson Response Times
4 Exhibit LLA-20 IAE&P letter to DHS 1103 1103
5 10-13-16
6 Exhibit LLA-27 Hellsgate ARCR 1041 1041 Comparative Analysis
7 12/9/16
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9
10
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13
14
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1 BE IT REMEMBERED that the above-entitled
2 and numbered matter came on regularly to be heard
3 before the Office of Administrative Hearings, 1400 West
4 Washington Street, Suite 101, Phoenix, Arizona,
5 commencing at 8:31 a.m. on the 15th day of December,
6 2016.
7 BEFORE: Administrative Law Judge Thomas Shedden
8
9 For the Applicant:
10 THE MEYERSON LAW FIRM, P.L.C. By Mr. Jeffrey Meyerson
11 2555 E. Camelback Road, Suite 140 Phoenix, Arizona 85016
12 480-305-0974 [email protected]
13
14 For the Intervenor:
15 FLETCHER, STRUSE, FICKBOHM & MARVEL, PLC Ms. Ronna L. Fickbohm
16 6750 N. Oracle Road Tucson, Arizona 85704
17 520-575-5555 [email protected]
18
19 For Arizona Department of Health Services, Bureau of Emergency Medical Services and Trauma System:
20 OFFICE OF THE ATTORNEY GENERAL
21 Education and Health Section Mr. Kevin D. Ray
22 Ms. Molly Bonsall Assistant Attorney General
23 1275 W. Washington Street Phoenix, Arizona 85007-2926
24 602-542-8328 [email protected]
25
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1 ALJ SHEDDEN: All right, good morning.
2 We are on the record in the matter of Hellsgate Fire
3 District dba Rim Country Fire and Medical Service,
4 applicant. This is Docket No. 2017A-EMS-0006-DHS.
5 Today is December 15, 2016. It's about 8:30 a.m. My
6 name is Administrative Law Judge Thomas Shedden. I've
7 been assigned by the Office of Administrative Hearings
8 to preside over this matter.
9 This is our fourth day of hearing, so
10 I'll just remind you that I've got the recording
11 device on. We're creating a transcript as well as
12 we go forward, so we've got to avoid interrupting
13 each other or talking over one another, that sort of
14 thing. We don't get a clear recording or transcript
15 if we don't adhere to that. So be aware of that,
16 please.
17 Also, the only food or drink allowed in
18 the hearing room is water. And I'll remind you there
19 should be some evaluation forms around if any or all of
20 you want to give our Director feedback on how we're
21 doing.
22 Let me just again ask if there's anyone
23 with you today you would like to introduce who you
24 haven't previously and/or if there are any preliminary
25 issues that you feel we need to address?
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1 No? All right.
2 Where we left off, we were going to go
3 to Life Line's presentation, so it looks like it will
4 be Dr. Racht first, correct?
5 MS. FICKBOHM: That's right, Your Honor.
6 ALJ SHEDDEN: All right. Why don't you
7 come on up.
8 THE WITNESS: Good morning.
9 ALJ SHEDDEN: Good morning. Let me go
10 ahead and get you sworn in, so if you would raise your
11 right hand.
12
13 EDWARD RACHT M.D.,
14 called as a witness on behalf of the Intervenor herein,
15 having been first duly sworn by the Administrative Law
16 Judge to speak the truth and nothing but the truth, was
17 examined and testified as follows:
18
19 ALJ SHEDDEN: All right. Go ahead and
20 state and spell your name for our record, please.
21 THE WITNESS: It's Edward Racht,
22 R-A-C-H-T.
23 ALJ SHEDDEN: All right. And I don't
24 know that you've been here the last few days, but
25 you've participated in our hearings before, I do know
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1 that. Kind of do a round-robin, starting with
2 Ms. Fickbohm's questions, and then going to the
3 attorneys for DHS and the applicant here, Hellsgate,
4 give them a chance to ask you whatever questions they
5 may have.
6 So do you have any questions or concerns
7 about how we're going to go forward this morning?
8 THE WITNESS: I do not.
9 ALJ SHEDDEN: All right. Whenever
10 you're ready, Ms. Fickbohm.
11
12 DIRECT EXAMINATION
13 BY MS. FICKBOHM:
14 Q. Good morning, Dr. Racht.
15 A. Good morning.
16 Q. Could you please tell the Judge what your
17 current professional position is?
18 A. So I'm the Chief Medical Officer for American
19 Medical Response and the Associate Medical Officer for
20 Evolution Health, which is an entity under Envision
21 Healthcare.
22 Q. I would like to talk to you about the career
23 path that led you to where you are today. So tell me
24 when you first became involved in emergency medical
25 services.
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1 A. So I had my first role in emergency medical
2 services in 1987; was involved in the Richmond
3 Ambulance Authority and had a faculty position at the
4 Medical College of Virginia and became medical director
5 for a multitude of volunteer and career Fire Department
6 and EMS entities in Virginia.
7 My path took me west to Texas, where I became
8 the full-time medical director for the City of Austin,
9 Travis County EMS system. I served in that capacity
10 for 13 years.
11 Q. And let me interrupt you there for a second.
12 I forgot the preliminary for that.
13 You are a licensed physician?
14 A. I'm a licensed physician.
15 Q. And in what states are you licensed?
16 A. Currently licensed in Texas and Virginia.
17 Q. And when you started the position in Virginia
18 that you first told us about, were you a licensed
19 physician at that time?
20 A. I was a licensed physician at that time.
21 Q. Okay. So after your Austin position, you
22 went there?
23 A. After Austin I took a Chief Medical Officer,
24 Vice-President of Medical Affairs position at -- in
25 Piedmont Healthcare in Atlanta at Piedmont Newnan
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1 Hospital in Georgia. And then from there joined
2 American Medical Response in 2010.
3 Q. 2010.
4 And can you tell us, generally speaking, what
5 your duties involve?
6 A. So my role involves, really, clinical
7 advocacy, facilitation. We have 130-plus medical
8 director -- physician medical directors throughout AMR
9 nationally, actually internationally, now. So I work
10 with those individuals. I work with healthcare systems
11 to really take the medical literature, the evidence,
12 the practice in emergency medical services, and
13 together formulate good operational approaches to
14 managing patients in a multitude of environments.
15 So facilitation, clinical conscious might be
16 a good term, advocacy for patient care, the science,
17 the evidence, oversight of our research efforts. So
18 we've got several -- have had several research projects
19 in the past as well.
20 Q. And is this all prehospital medicine?
21 A. So it has historically been prehospital
22 medicine. So the overwhelming majority is. Now some
23 of that is posthospital medicine. So in the newer
24 arena it's the EMS entity, the term mobile integrated
25 healthcare, where paramedics, EMTs, nurses and
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1 practitioners would see patients in conjunction with
2 the healthcare system after they've been discharged, so
3 out of hospital.
4 Q. And with regard to mobile integrated
5 healthcare, which we also refer to as community
6 paramedicine, correct?
7 A. They are similar.
8 Q. Similar.
9 What has American Medical Response's role in
10 the national mobile integrated healthcare/community
11 paramedicine program discussions been?
12 A. So we've been very involved in that. As a
13 matter of fact, there's a JEMS article that we
14 published with the terminology of mobile integrated
15 healthcare group of AMR and non-AMR and practitioners
16 that talked about mobile integrated healthcare.
17 We have been very involved with exploring the
18 metrics associated with it, the credentialing, the
19 practices, the approaches, deployment strategies, level
20 of practitioner that's appropriate for level of care.
21 We offer some form of mobile integrated
22 healthcare program in about 38 or 39 AMR practices
23 nationally. We have published with the Medtronic
24 Foundation the guidebook, the playbook for mobile
25 integrated healthcare implementation. We've partnered
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1 with the International Association of Fire Chiefs on a
2 webinar on mobile integrated healthcare.
3 So we're very involved in its evolution, in
4 its beginnings and kind of working with our colleagues
5 to figure out what works best in kind of the changing
6 world of healthcare.
7 Q. And is that evolution still underway?
8 A. That evolution, Counselor, will be underway
9 till all of our families are long, long gone. So it
10 will constantly be changing.
11 Q. I want to back up and just pin down a couple
12 terms you used.
13 When you say "a JEMS article," what is that?
14 A. I'm sorry. It's Journal of Emergency Medical
15 Services.
16 Q. And is that an important journal in your
17 field of medicine?
18 A. It's one of two journals that are very
19 commonly referred to for kind of current practices in
20 emergency medical services. EMS World is the -- EMS
21 Magazine is the other one.
22 Q. And you referenced the Medtronic Foundation
23 Playbook. What is that?
24 A. So the Medtronic Foundation Playbook is a --
25 it's a published document, a consensus document of a
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1 group of providers, again, within AMR and outside of
2 AMR, who came together to really try and encapsulate
3 and summarize principles of mobile integrated
4 healthcare, practice approaches, and clinical metrics
5 that were important.
6 And Lynn White, one of our colleagues in
7 American Medical Response, was the principal author of
8 that document.
9 Q. You testified that 38 to 39 AMR practices
10 nationwide are currently doing mobile integrated
11 healthcare, correct?
12 A. That's correct.
13 Q. Are you aware of any organization or entity
14 that's doing more than AMR is?
15 A. I am not aware of any organization that does
16 more mobile integrated healthcare sites than AMR.
17 Q. I'm going to come back to mobile integrated
18 healthcare in just a second, but I want to finish with
19 your background and experience.
20 I have up in front of us what's been marked
21 for purposes of identification as Life Line Ambulance
22 LLA-13e, even though it says AMR-13 at the top. And
23 this is your professional qualifications?
24 A. That's correct.
25 Q. And at the end of Page 1 we have your
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1 certifications, and then on Page 2 your education and
2 then a long list of awards and honors, correct?
3 A. That's correct.
4 Q. And then after that is followed by -- well, I
5 want to go just back to the awards and honors for just
6 a second.
7 In 2015 you received the Pinnacle Dr. Joseph
8 Ornato Award for Clinical Leadership. Tell me what
9 that is.
10 A. So Dr. Joe Ornato is the chair of emergency
11 medicine at Virginia Commonwealth University. He was
12 my mentor. He hired me into emergency medicine when I
13 was a little puppy at the time. And he has been
14 instrumental in resuscitation research, in emergency
15 medical services. And the Fitch & Associates Group for
16 Pinnacle established an award in his honor, with his
17 contributions to emergency medicine, and I was the
18 first -- very honored to be the very first recipient of
19 that award in 2015.
20 Q. I'm not going to have you detail any of your
21 other awards. It would just take all day.
22 You've already summarized your professional
23 path.
24 You also have held a variety of academic
25 positions, as detailed beginning on Page 3, correct?
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1 A. That's correct.
2 Q. Some continuing to today.
3 And then you have other background in
4 emergency medical service that starts on Page 4 of your
5 CV, correct?
6 A. That's correct.
7 Q. You also have listed for us your work in
8 international medical care. And starting on Page 6,
9 maybe -- what did I do? I went all the way to the end.
10 Sorry. We have the committees and boards that you have
11 served on and continue to serve on, correct?
12 A. That's correct.
13 Q. And that includes the Institutional Review
14 Board for the National Academies of Emergency Dispatch,
15 correct?
16 A. That's correct.
17 Q. And after that, starting on Page 9, we have
18 your publications that you have either authored or been
19 involved in the authoring of, correct?
20 A. That's correct.
21 Q. And I think that takes up about five pages,
22 if I'm right.
23 On here it says "Poster Presentation." Can
24 you explain to us what that is?
25 A. Poster presentations are academic approaches
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1 where a study or a message is encapsulated in a poster,
2 a single poster, in abstract form, that usually at
3 professional meetings individuals will present their
4 poster. It's often a precursor for a fully published
5 article.
6 Q. And this includes one you did in 2001 for a
7 comparison of ambulance driving times with and without
8 lights and sirens, correct?
9 A. That's correct.
10 Q. Because not every ambulance response requires
11 a lights and sirens -- lights and siren utilization,
12 correct?
13 A. That's correct.
14 Q. I'm not going to ask you to go through that.
15 Your resumé, I believe, speaks for itself.
16 MS. FICKBOHM: I would move for
17 admission of LLA-13e, Your Honor.
18 ALJ SHEDDEN: Is there any objection on
19 13e?
20 MR. MEYERSON: No objection.
21 ALJ SHEDDEN: 13e is admitted.
22 BY MS. FICKBOHM:
23 Q. Going back to mobile integrated healthcare,
24 tell us what the challenges are associated with putting
25 a mobile integrated healthcare program in place,
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1 particularly in a small or rural community.
2 A. So if I could, I would start with kind of the
3 global challenges of mobile integrated healthcare.
4 Q. Sure.
5 A. And then maybe drill down to different
6 venues.
7 The concept behind mobile integrated
8 healthcare, it's a funny terminology, but it fits best.
9 It's kind of the 910 and the 912 of 911. So it is
10 designed to use the skill set, the resources, the
11 deployment, the availability of a traditional EMS
12 system to prevent utilization of 911, Emergency
13 Department visits, to try and manage patients before
14 they deteriorate to the point that they need an acute
15 level of care.
16 On the flip side, the 912 part, the concept
17 is that those same individuals, with the right
18 training, with the right credentialing, would provide
19 postacute care. So they would go to the patient's
20 home, to wherever the patient was. In some communities
21 they would reach out to find homeless patients to try
22 and manage them postevent, but to try and create a
23 transition that improves their health.
24 So the idea is to use the brain power, the
25 skill set, the resources of an EMS system to help
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1 prevent the use of the acute side.
2 It depends on many, many factors, and I've --
3 in my career, short time that MIH has been around,
4 there are no two mobile integrated healthcare programs
5 that are the same, but they are designed to be able to
6 manage a certain population.
7 In an urban environment, the volume of
8 patients would allow for that mobile integrated health
9 component to be relatively busy if it's a dedicated
10 approach.
11 In an urban -- sorry. In a rural or frontier
12 environment, the challenges that many see are being
13 able to access patients. There is a lot of drive time
14 in between. That's personnel time. So there's drive
15 time in between, and there's often difficulty in
16 getting other practitioners involved in their care.
17 That said, there are advantages in both
18 sides. So there are advantages in the urban side to be
19 able to rapidly get to patients to prevent 911; and on
20 the rural and frontier side, to be able to decrease the
21 need for them to travel great distances to emergency or
22 acute healthcare.
23 Q. When you say "a frontier environment," what
24 do you mean by that?
25 A. I'm sorry. That's probably a Texas term. My
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1 apologies. I'm surprised you guys don't. It's the
2 Texas equivalent, so it's a -- it is not wilderness,
3 but it is --
4 Q. Super-rural?
5 A. It is super-rural. It is very difficult
6 access because of distance or ability to reach that
7 patient.
8 Q. Are these programs easier to set up if you
9 have a community where the ownership of the EMS
10 resources is vested in one entity or organization, such
11 as a City that runs a hospital runs the ambulance, runs
12 fire?
13 A. So the very -- the very purpose of mobile
14 integrated healthcare, the I part of integrated, is
15 that there is no single practitioner, whether he or she
16 is a physician, a case manager, dentist, a paramedic,
17 who can manage all of the components of a patient that
18 they may need over a spectrum of time.
19 So by definition, mobile integrated
20 healthcare means that that process has to integrate
21 with the hospital side, the healthcare system side, the
22 municipal side, governmental side, ambulance side. The
23 best mobile integrated healthcare programs are programs
24 that essentially bring those different players together
25 in an integrated way.
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1 Q. And given the fact that AMR is the leader in
2 this field and there's 37 to 38 operations and AMR has
3 hundreds and hundreds of operations, what's the
4 challenge of having it everywhere? Why isn't it just
5 everywhere?
6 A. So mobile integrated healthcare, again, from
7 a clinical standpoint, is a fabulous idea. It is a
8 healthcare -- it's a healthcare strategy that would
9 potentially improve the health of patients. It would
10 decrease deterioration. It would improve their
11 transition back after an acute admission or acute
12 episode.
13 So clinically, I think the mobile integrated
14 healthcare strategy is ideal for helping to manage an
15 historically tough population.
16 Logistically, part of the challenge and
17 really a big part of the challenge -- and the National
18 Association of EMTs published a survey about a year and
19 a half or two years ago. The challenge has been
20 funding it. So funding a mobile integrated healthcare
21 program, if you look at what it does, mobile integrated
22 healthcare says I'm going to decrease your -- I'm going
23 to decrease your ambulance transports, I'm going to
24 decrease your Emergency Department visits, I'm going to
25 decrease your hospitalizations, I'm going to decrease
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1 everything that in today's fee-for-service world is
2 generating revenue. So it essentially takes that
3 patient out of the current system and puts it into this
4 mobile integrated healthcare system.
5 The challenge with that is that there is no
6 direct -- consistent direct way to fund mobile
7 integrated healthcare at that level. So it often
8 becomes a program that's done as part of a routine
9 response. So keeping mobile integrated healthcare
10 sustainable is probably the number one challenge.
11 The number two challenge is, unfortunately --
12 and I would underline unfortunately. -- the U.S.
13 emergency medical services, emergency healthcare really
14 haven't come together to define credentials,
15 competencies, practices, approaches, metrics,
16 documentation requirements. So there could be a mobile
17 integrated healthcare program that essentially used
18 on-duty practitioners, paramedics and EMTs, that had no
19 additional training in things like the continuum of
20 care or postacute care, who may use the emergency
21 medical services tools, but not do what the patient
22 needs.
23 On the flip side, there are mobile integrated
24 healthcare programs that are using more advanced
25 diagnostics, that are using diagnostics to obtain -- or
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1 to facilitate imaging, to facilitate blood and specimen
2 drawing for laboratory analysis.
3 So the spectrum is wide, and there's not
4 consensus on exactly what those entities should be
5 doing.
6 Q. Thank you.
7 I'm going to show you what's been marked as
8 LLA-3j, and this is a poster on the mobile integrated
9 health practice, correct?
10 A. That's correct.
11 Q. And AMR was involved in the authoring of
12 this?
13 A. That's correct.
14 MS. FICKBOHM: I would move for
15 admission of 3j.
16 ALJ SHEDDEN: Is there any objection on
17 Life Line 3j?
18 MR. MEYERSON: No objection.
19 ALJ SHEDDEN: All right. 3j is
20 admitted.
21 BY MS. FICKBOHM:
22 Q. I'm showing you next LLA-3k. And just for
23 purposes of the record and ease of reference, all of
24 the exhibits I'm going to refer in Dr. Racht's
25 testimony are going to be LLA.
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1 So can you tell us what this is,
2 Dr. Racht?
3 A. So this was an article in Modern Healthcare
4 on mobile integrated healthcare practice that was
5 published as an overview of some of the potential
6 solutions of the strategies that I just described.
7 And the group of authors on this particular
8 article are reflective of -- so not all of those are
9 AMR or Envision Healthcare providers; and that was
10 purposeful, to bring in experts from both within and
11 outside of AMR to discuss that.
12 Q. Scott Bourn, yourself, Lynn White are all AMR
13 people?
14 A. So at the time of publication of this
15 article, Eric Beck, Alan Craig, Scott Bourn, myself,
16 and Lynn were AMR.
17 Q. And this goes into additional detail about
18 what you just testified about?
19 A. That's correct.
20 MS. FICKBOHM: I would move for
21 admission of 3k?
22 ALJ SHEDDEN: Is there --
23 MR. MEYERSON: I'm sorry. No objection.
24 ALJ SHEDDEN: All right. 3k is
25 admitted.
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1 BY MS. FICKBOHM:
2 Q. This one is a little harder to look at
3 because of the way it prints out, but I'm showing you
4 3l, "EMS," and the next page is going to say "at the
5 Healthcare Table. As the Community Paramedicine
6 Concept Evolves, EMS Will Play an Integral Part."
7 Who was involved in the publication of this?
8 A. So that particular article, the individuals
9 that were -- that participated in the Modern Healthcare
10 article were also involved in this concept.
11 This particular article is of note, if you
12 scroll down, Ronna, in the -- I'm sorry. Scroll back
13 up. Stop.
14 Q. Okay.
15 A. So if you -- we struggled for a significant
16 amount of time trying to define your question earlier,
17 community paramedicine and the new term, "mobile
18 integrated healthcare." So this article was the first
19 article published in the literature that used the term
20 "mobile integrated healthcare," and we spent
21 significant time to be thoughtful in trying to define
22 what an entity could be who delivered that kind of
23 care.
24 Q. And so this is from April of 2013, correct?
25 A. That's correct. I -- yes, that's correct.
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1 Q. Demonstrating how new this concept and goal
2 really is, correct?
3 A. That's correct.
4 MS. FICKBOHM: I would move for
5 admission of 3l.
6 MR. MEYERSON: No objection.
7 ALJ SHEDDEN: All right. 3l is
8 admitted.
9 BY MS. FICKBOHM:
10 Q. And my last one on mobile integrated health,
11 Dr. Racht, is AMR or LLA-3p. Do you recognize what
12 this is?
13 A. Yes. So if you'll scroll down just a little
14 bit more to the bottom of that page.
15 So this is the Medtronic Philanthropy's
16 Guidebook, Playbook that I referred to earlier in
17 testimony, on building and maintaining a mobile
18 integrated healthcare program.
19 MS. FICKBOHM: I would move for
20 admission of 3p.
21 MR. MEYERSON: No objection.
22 ALJ SHEDDEN: 3p is admitted.
23 BY MS. FICKBOHM:
24 Q. Let's talk for a minute about AMR, what it is
25 and what it does.
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1 And I want to tell you that you have a mouse
2 right in front of you, and you have everyone's
3 permission to use that mouse as much as you want. And
4 I'm happy to do it for you, but if you want to take it
5 yourself and move it around.
6 A. All right.
7 Q. Can you tell us what 3ee?
8 A. So 3ee is an infographic that we created
9 three years ago. It's a summary document that just
10 takes our -- some of our response statistics, some of
11 our metrics, and puts them into one infographic.
12 Q. And so can you tell us what this summarizes
13 with regard to what AMR does?
14 A. Yes. So this particular infographic
15 obviously -- and I won't read through all this, unless
16 you would like for me to.
17 Q. No, no, no. You can just scroll through.
18 A. It looks at vital signs. It looks at
19 critical intervention. Just a quick note. We don't
20 deliver 3 babies a day. It's 2.8-something, but a .2
21 is a very awkward baby to categorize. 4.4 million
22 patients, 87 pediatric patients transported every hour.
23 Part of what we use this for is to remind
24 ourselves, our practitioners, that if -- because we are
25 big, we have to be good. And I know that sounds very
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1 corny. But this illustrates that we really have to
2 have an impact on clinical care that's thoughtful,
3 that's evidence-based. If we're transporting
4 87 pediatric patients an hour, we should be very
5 comfortable, confident in that patient population.
6 6,275 vehicles.
7 Q. And I just want to stop you for a minute.
8 You said this was from a few years ago. Have these
9 numbers increased since then?
10 A. These numbers have increased with every
11 publication, yes.
12 And, again, this is probably the -- this is
13 the number of communication centers. We are the
14 national FEMA provider for emergency medical response
15 for all four FEMA regions, and we have two national
16 interprofessional command centers. They are medical
17 command centers that are actually licensed practices of
18 medicine that are community -- or they're based on the
19 mobile integrated healthcare environment and then
20 emergency medical dispatch. We have more
21 CAAS-accredited ambulances.
22 Q. What's CAAS?
23 A. I'm sorry. The Commission on Accreditation
24 of Ambulance Services.
25 We're proud of this one, or I'm proud of this
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1 one. I think we all are. We are the second largest
2 training center for the American Heart Association in
3 the country.
4 Q. What's the first?
5 A. The VA, interestingly. So the VA is number
6 one. We are number two.
7 We're also the largest provider of
8 prehospital education in the U.S.
9 This particular metric -- and I think you
10 might be talking about it later.
11 Q. We have more specifics on that one, yes.
12 A. Talks about our CPR Challenge. And I believe
13 that's it in this document.
14 MS. FICKBOHM: Move for admission of
15 3ee.
16 MR. MEYERSON: No objection.
17 ALJ SHEDDEN: All right. 3ee is
18 admitted.
19 BY MS. FICKBOHM:
20 Q. I want to talk to you about AMR's core
21 philosophies.
22 Did there come a point in time where the
23 leadership at AMR got together and actually reduced
24 those core philosophies, pulling -- and core attentions
25 to writing?
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1 A. Core attentions as in the --
2 Q. As in what --
3 A. Clinical focus, so the Things that Matter?
4 Q. Yes, clinical focus, right.
5 A. If you're referring -- there we go.
6 So we --
7 Q. And I've got up on the screen Exhibit 3u.
8 A. So we, several years ago -- actually, more
9 than several years ago. Four and a half or five years
10 ago, as we looked nationally at what we were doing and
11 looked at our quality and performance approach, we
12 realized that we had a ton of data and very little
13 information. So we were able to capture a lot of
14 metrics. We had a lot of data. But we weren't very
15 good at being able to take that data and assimilate it
16 into an effort, a practice, and improvement.
17 So it took us a little more than a year,
18 again, with experts from within and outside of AMR, to
19 sit down and create the clinical metrics that we felt
20 were the most important clinical metrics to focus on as
21 a national organization at the individual local level,
22 so that we could study them, improve them, and do what
23 we could to improve patient outcome in those metrics.
24 So we created the metrics, and we,
25 interestingly, struggled in what to call them and
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1 landed on the very scientific "Things that Matter"
2 phrase.
3 But the concept was that we would, as a
4 national organization, in addition to all the reporting
5 elements and quality improvement and performance
6 efforts at the local level, from a national standpoint
7 every AMR practice would focus on patient safety,
8 cardiac arrest and resuscitation, pain/discomfort,
9 respiratory distress, STEMI/stroke, which are
10 time-dependent, and then effective management of
11 significant trauma.
12 So our metrics surrounding that, our
13 education surrounding that, our focus surrounding that,
14 our data definitions surrounding that at the national
15 level all became uniform so that we could track our
16 performance and what our efforts were to improve those
17 things.
18 Q. And is this definition also important to a
19 concept we're going to talk about a little later called
20 benchmarking?
21 A. That's correct.
22 So part of the principle behind Things that
23 Matter is, if I am an AMR practice in one environment
24 and I have a pain relief rate of improving pain in
25 72 percent of the patients who present with pain, I can
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1 benchmark myself against what the national numbers are.
2 If the national numbers are that's 96 percent, then
3 that would lead me to believe that I had some room to
4 grow and improve that.
5 So the idea behind that within AMR was to
6 identify the high performers, so that they could be the
7 teachers for the rest of us, and to identify those that
8 needed improvement or, frankly, had to have a pretty
9 aggressive effort to come in and focus on a particular
10 clinical condition.
11 MS. FICKBOHM: I would move for
12 admission of 3u, Your Honor.
13 MR. MEYERSON: No objection.
14 ALJ SHEDDEN: All right. 3u is
15 admitted.
16 BY MS. FICKBOHM:
17 Q. Well, and I'm showing you -- that's not the
18 one I want to go to. Sorry. Sorry.
19 Showing you what's been marked as 3r, is this
20 a companion document to 3u?
21 A. Yes, it is.
22 Q. With additional detail?
23 A. Yes, it is.
24 MS. FICKBOHM: Move for admission of 3r.
25 MR. MEYERSON: No objection.
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1 ALJ SHEDDEN: All right. 3r is
2 admitted.
3 BY MS. FICKBOHM:
4 Q. I would like to have you talk briefly and
5 from a high level about an example of each of these
6 points on what really matters.
7 So let's talk first about ensuring safe
8 patient care and transport. I'm going to turn to 3ff,
9 and can you tell us what this is?
10 A. So this was a joint effort between -- really,
11 led by Alex Isakov, who is one of our medical directors
12 and a physician at Emory University in Atlanta. This
13 was a result of the Ebola, the U.S. Ebola crisis.
14 So a group of us -- the organizations and
15 agencies are listed on the document. A group of us put
16 together standard operating procedures for patient
17 handoff. It's patient population that's obviously
18 highly infectious. It was a different population that
19 EMS had not seen before. So this group provided this
20 through the efforts of the Centers for Disease Control
21 and Prevention, and this was published as guidance.
22 MS. FICKBOHM: Move for admission of
23 3ff.
24 MR. MEYERSON: No objection.
25 ALJ SHEDDEN: All right. 3ff is
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1 admitted.
2 BY MS. FICKBOHM:
3 Q. 3gg, can you tell us what this is?
4 A. So this is the same approach as I described
5 previously. This happens to be air to ground because
6 of the -- at least in the early phases of the potential
7 Ebola crisis in the U.S., there was a lot of discussion
8 about moving patients by air to designated, qualified
9 and appropriate centers nationally. So the question of
10 moving them from air to ground and how to safely do
11 that for providers and for patients is addressed in
12 this.
13 Q. Who transported the infamous identified
14 Patient 1 for Ebola in the United States?
15 A. So we transported two. So the two nurses
16 that were at Texas Presbyterian we transported from the
17 hospital to Love Field in Dallas.
18 MS. FICKBOHM: I would move for
19 admission of 3gg.
20 MR. MEYERSON: No objection.
21 ALJ SHEDDEN: 3gg is admitted.
22 BY MS. FICKBOHM:
23 Q. And I have in front of you 3dd. And can you
24 talk about how the concepts in this article address
25 safe patient care and transport?
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1 A. So this is an interesting article, in some of
2 our AMR practices and with medical directors who we
3 work with, that looked at identification of patients
4 that had an anticoagulant or antiplatelet therapy and
5 who also had head trauma.
6 So there's a real interest in --
7 appropriately, in identifying patients who have head
8 trauma who may be at risk for intracranial or inside
9 the head hemorrhage. Those patients have a much higher
10 mortality. They are much more acute and often need to
11 go to a higher level of care.
12 So this was the first study in this group
13 that really looked to try and ascertain whether, during
14 the management of these head trauma patients, medics
15 were able to accurately identify the presence of one of
16 those or any of those anticoagulants or antiplatelet
17 drugs, which could then be used to make better
18 decisions about either destination or acuity of that
19 patient.
20 Q. And this is from September of 2016?
21 A. That's correct.
22 Q. And in general, is this level of patient
23 analysis and treatment something that's done by first
24 responders or by ambulance transport providers?
25 A. So it can be done by the spectrum. Something
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1 of this level is often done in the more intensive deep
2 dive of patient assessment. So any patient that's
3 assessed anywhere gets -- by all of us, whether in the
4 Emergency Department or in the field, that initial
5 assessment is essentially to figure out what's going to
6 hurt me, what's going to hurt them, what's acutely in
7 need of intervention for lifesaving skills; is the
8 patient breathing, not breathing, et cetera. And then
9 from there, continued evaluation, examination,
10 assessment, to figure out other variables that would
11 impact their care.
12 So in this particular case, this is one of
13 those secondary levels of assessment to then further
14 drill down and identify whether a patient may need a
15 higher level of care or different level of care to be
16 more appropriate or would be at higher risk.
17 MS. FICKBOHM: Move for admission of
18 3dd.
19 MR. MEYERSON: No objection.
20 ALJ SHEDDEN: 3dd is admitted.
21 BY MS. FICKBOHM:
22 Q. Let's talk about cardiac arrest
23 resuscitation, the second point on the list.
24 First of all, I want you to tell me, like,
25 you know, how big a problem is -- or how big an issue
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1 is this in the United States?
2 A. So it's huge. Let me clarify that. It is
3 a -- it's a large issue for acute healthcare providers,
4 because without the appropriate intervention, the
5 outcome is clear. The patient will not survive the
6 event. With inappropriate intervention the patient
7 could potentially survive, but be neurologically
8 impaired.
9 It's a time-dependent, resource-dependent,
10 very, very specific illness that EMS has historically
11 used as kind of the benchmark of performance and
12 success of an EMS system historically.
13 So we know what makes a difference. We know
14 how to impact that. We know how important time is, and
15 we know how important an integrated system is to manage
16 them to the best possible outcome.
17 Q. So with regard to what AMR has directed its
18 time and attention and resources to to address this
19 point of interest and focus, you have something known
20 as the CARES program?
21 A. Yes. So CARES is the Cardiac Arrest Registry
22 to Enhance Survival. It was initially a federally
23 funded program through the Centers for Disease Control
24 and Emory University in Atlanta. It is now -- it now
25 lives at Emory University in Atlanta.
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1 The principle behind CARES, it's a tremendous
2 principle, is that anyone who's involved in managing a
3 cardiac arrest patient -- "anyone" meaning the 911
4 communication piece, the first response piece, the
5 ambulance piece, the healthcare system piece. -- would
6 enter data into a National Registry to be able to look
7 at survival, to be able to track what interventions,
8 what intervals could make a positive or, conversely, a
9 negative difference in survival, and to serve as a
10 national benchmark in performance of a system, a
11 healthcare system, in this particular problem.
12 Q. And so this one dated 2013 collects data
13 from --
14 A. 2012.
15 Q. Is this 2012 data or is this --
16 A. It's 2012.
17 Q. Yeah. So this is national data for January
18 through December 2012, correct?
19 A. Correct.
20 Q. And on Page 2, AMR as a group is benchmarking
21 itself against national users of the sys -- national
22 entities that are participating in the program?
23 A. So that's correct.
24 So this summary document is a document that
25 we send to all of our colleagues in AMR as kind of the
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1 assessment of the year before. I think it's important,
2 this data comes through the CARES Registry program. So
3 hospital outcomes, the hospitals report those outcomes.
4 This isn't self-reported. But we use this to benchmark
5 what AMR CARES participant survival and other metrics
6 are versus what the overall national group data is.
7 Q. And so this allows you to look and see, if we
8 look at everyone and then we look at just us, are we
9 doing it worse, are we doing it better or the same?
10 A. That's correct.
11 MS. FICKBOHM: I would move for
12 admission of 3w, Your Honor.
13 MR. MEYERSON: No objection.
14 ALJ SHEDDEN: All right. 3w is
15 admitted.
16 BY MS. FICKBOHM:
17 Q. 3x is the same collection of information for
18 calendar year 2013?
19 Yes?
20 A. I'm sorry. Yes.
21 Q. And so here we see that with regard to the
22 Utstein Survival and Bystander Survival, AMR as a
23 national group has a slightly lower rating than the
24 national --
25 MR. MEYERSON: I'm going to object, just
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1 because counsel is testifying about this instead of
2 letting the witness testify to it.
3 ALJ SHEDDEN: All right. I'll just have
4 you go ahead and ask a question, Ms. Fickbohm.
5 BY MS. FICKBOHM:
6 Q. The last two categories, AMR as a national
7 group has lower percentages than CARES as a national
8 group. Are you able to comment on that?
9 A. Yes. So there are -- if you look at how
10 CARES reports their data, they report it in a variety
11 of different formats. So Overall Survival to Hospital
12 Discharge, which tends to be the practical approach;
13 the Overall Survival with Good or Moderate Cerebral
14 Performance, so those are patients who survive the
15 event who have -- who are neurologically intact.
16 And then the three metrics that are listed
17 below, Bystander CPR, Utstein, and Utstein Bystander
18 CPR, break down these populations into very distinct
19 subsets.
20 So we would expect to see, for example,
21 Utstein Survival, which are patients who are the
22 definition below, they are witnessed by a bystander and
23 they're found in a shockable rhythm. That's a very
24 distinct subset of patients, as is the Utstein
25 Bystander. So I may have mixed those up, but they are
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1 both the same. They are defined as patients who are
2 witnessed by a bystander. They are found to be in a
3 shockable rhythm, historically the most treatable and
4 survivable rhythm.
5 So this a good example. This particular year
6 was a very good example. So our overall survival and
7 our neurologically intact survival was higher than the
8 national average. In looking at the subpopulations, it
9 allowed us to focus on -- to improve even more, it
10 allows to focus on those patient populations with
11 shockable witnessed rhythms and sent the message about
12 the importance of getting out to the community, educate
13 the community to call us rapidly and learn
14 compression-only CPR.
15 Q. And is that something that AMR, in fact, did?
16 A. So we did do that, and we very aggressively
17 did that. As a matter of fact, we modeled our efforts
18 after the landmark paper that the state of Arizona did.
19 So Ben Bobrow and Dan Spaite and his colleagues really
20 published the first paper that said that bystander
21 compression-only or hands-only CPR, when that program
22 is rolled out to a community, you can substantially
23 improve survival.
24 So we took that concept, and every year since
25 '13 we've done what we call the AMR World CPR
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1 Challenge. So our practices nationwide will
2 essentially choose a day -- this coming year it will
3 actually be a week. -- that we -- our efforts are to
4 get in the community in any way we can to show the
5 community the importance of compression-only CPR. It's
6 aimed at the data that you see in the bottom two
7 segments here, to get the public more comfortable with
8 doing compression-only CPR and being able to activate
9 911 quickly in the case of an unconscious pulseless
10 patient.
11 Q. And using that kind of benchmarking analysis,
12 did you actually end up seeing improvement?
13 A. So we did see improvement. So I would love,
14 I would love to be able to say it was a direct result
15 of that effort. Cardiac arrest is a process that's
16 dependent on a multitude of things, but what it is --
17 what it does show us is that we have been able to
18 improve survival and to maintain survival higher than
19 the national average over our CARES journey.
20 MS. FICKBOHM: Move for admission of 3x.
21 MR. MEYERSON: No objection.
22 ALJ SHEDDEN: 3x is admitted.
23 BY MS. FICKBOHM:
24 Q. I'm not going to have you go through it, but
25 I just want to ask you to confirm that 3y is the same
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1 data for calendar year 2014 as reported in 2015?
2 A. That's correct.
3 Q. And 3z, the following year?
4 A. That's correct.
5 MS. FICKBOHM: Move for admission of 3y
6 and 3z.
7 MR. MEYERSON: No objection.
8 ALJ SHEDDEN: All right. 3y and 3z are
9 admitted.
10 BY MS. FICKBOHM:
11 Q. And I'm showing you 3cc, and is this document
12 related to what you just talked to with regard to CPR
13 Challenge?
14 A. It is. This is a document that we created as
15 almost a newsletter document to our own colleagues, as
16 well as to the outside world, that said this is why we
17 do this and this is what we can accomplish in terms of
18 numbers of patients or folks who are trained and then
19 the potential increases in utilization of bystander
20 CPR.
21 Q. And since I know you don't have the numbers
22 memorized, could you just state for the record how many
23 people AMR trained through its CPR World Challenge in
24 2013, 2014, 2015, 2016, and total since the program was
25 initiated?
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1 A. So per the document, in 2013 we trained
2 54,885; in 2014, it was 61,883; 2015, 67,047; and then
3 this past May, 50,591. So our total was 234,405.
4 MS. FICKBOHM: Move for admission of
5 3cc.
6 MR. MEYERSON: No objection.
7 ALJ SHEDDEN: 3cc is admitted.
8 BY MS. FICKBOHM:
9 Q. I would like to move through the remaining
10 points perhaps in a little quicker fashion.
11 Reduction of pain and discomfort is next on
12 the list. I'm showing you what's been marked as 3aa.
13 Could you tell us, generally speaking, what this is?
14 A. This is a graph that showed nationwide our
15 ability to decrease pain. So pain and discomfort was a
16 thing that mattered. We needed to measure it to see
17 how we were impacting it. What we quickly found,
18 unexpectedly, was that we were not -- we were often not
19 identifying two points of time of a pain assessment.
20 So if we had one pain score, we couldn't measure
21 improvement because we didn't have a second pain score.
22 So you can see in the middle, September 2014,
23 our efforts focused -- we shifted to an education that
24 said you have to get two pain scores in order to
25 identify that there is improvement or not.
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1 So this is twofold. One is it improved our
2 ability dramatically to assess what we do, and the
3 other is it showed that we were able to improve pain in
4 that patient population.
5 Q. And that was an effort done nationwide?
6 A. It was an effort done nationwide. It was
7 done at the local level and choreographed from a
8 national perspective.
9 MS. FICKBOHM: Move for admission of
10 3aa.
11 MR. MEYERSON: No objection.
12 ALJ SHEDDEN: 3aa is admitted.
13 BY MS. FICKBOHM:
14 Q. The next item on the list of Things that
15 Matter is relief of -- I'm sorry, safe and efficient
16 management of airways and ventilation. Can you tell us
17 how 3a relates to that?
18 A. So this was, again, a study that essentially
19 looked at the prevalence of hyperventilation, meaning a
20 ventilation rate or a breathing rate which was higher,
21 in patients with a closed head injury.
22 Dan Spaite, Uwe Stolz, the entire University
23 of Arizona team has been very involved internationally
24 in looking at traumatic brain injury, head trauma. We
25 have, obviously, a large patient population nationally,
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1 so putting the two of those together has been, we
2 think, collectively beneficial in investigating what
3 makes a difference and doesn't.
4 Q. And do any of these studies -- you do the
5 studies and then you're like, wow, we shouldn't be
6 doing something we've been doing?
7 A. If studies don't identify that, then you're
8 not looking at the right thing. So the purpose of
9 investigation is to identify what makes a positive
10 difference and what makes a potential negative
11 difference, so that that negative difference can be
12 identified and changed.
13 Q. When we talk about relief of respiratory
14 distress, your next point, would this also be an
15 example of AMR's efforts in that regard?
16 A. This is a component of that.
17 MS. FICKBOHM: I would move for
18 admission of 3a.
19 MR. MEYERSON: 3a. No objection.
20 ALJ SHEDDEN: 3a is admitted.
21 BY MS. FICKBOHM:
22 Q. With regard to recognition and treatment of
23 STEMI and stroke, can you just orally give us an
24 example of AMR's efforts, studies, investigations?
25 A. So we've been -- we very aggressively
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1 provided educational tools. We look at intervals.
2 We've worked with one of our partners, Physio-Control,
3 on monitors to identify compression intervals,
4 appropriate data and reports to manage how we
5 effectively respond to two very time-dependent
6 processes.
7 Stroke is really interesting, because the
8 world of stroke management has changed dramatically
9 even in the past six months. So there's an evolving
10 new concept of not just identifying a stroke, but
11 identifying a stroke that occurs in a large vessel as
12 opposed to a small vessel.
13 The difference being that these patients may
14 need to go to a different kind of a center. So there
15 are a lot of efforts nationally to figure out what
16 identifies those patients so that they can be taken to
17 the right level of care, and we've been involved in
18 many of those.
19 Two days ago I spoke to the California
20 medical directors about stroke CT ambulances. So there
21 are now ambulances that have CT scanners in them that
22 can respond to strokes.
23 Q. And the last point is effective and timely
24 trauma care.
25 Well, first, before we go there, could you
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1 please, for the record, define what STEMI is,
2 S-T-E-M-I, the acronym?
3 A. I'm sorry. ST segment elevation myocardial
4 infarction.
5 Q. Heart attack?
6 A. Heart attack.
7 Q. I won't ask you why you guys always have to
8 have these big, long, complicated terms for things,
9 but...
10 A. Lawyers don't.
11 Q. Exactly.
12 So the last point on the What Matters list is
13 effective and timely trauma care. I have Exhibit 3n up
14 in front of you. Can you tell us how this relates to
15 that concept?
16 A. Yes. This -- and, unfortunately, this has
17 become an important paper, given what's happening
18 nationally. This was an evidence-based guideline in
19 conjunction with the American College of Surgeons to
20 identify principles of hemorrhage control. Lynn White
21 from AMR was a participant in this consensus process.
22 This particular article lays out an
23 evidence-based approach to managing hemorrhage and
24 bleeding. We've now incorporated, as many entities
25 have, the principles in this for managing active
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1 shooter/hostile events. And, unfortunately, it's our
2 changing world. But it provides some good guidance on
3 managing this patient population.
4 MS. FICKBOHM: Move for admission of 3n.
5 MR. MEYERSON: No objection.
6 ALJ SHEDDEN: All right, 3n is admitted.
7 BY MS. FICKBOHM:
8 Q. Can you talk for a couple minutes about how
9 the national attention and efforts you're involved with
10 benefit local operations, you know, individual
11 operations, whether it's CON 58, it's a Maricopa County
12 AMR operation, it's an AMR operation in Florida? How
13 do your national efforts benefit the local operations?
14 A. So I think the best way to summarize it is
15 that we have -- it's the Buzz Lightyear/Uni-Mind.
16 Sorry for the analogy, but the concept that you have so
17 many minds, so many folks who had experience and
18 expertise, who can contribute to potential solutions.
19 I think as an organization, AMR nationally, I
20 think we're stronger because we can identify who
21 understands certain things the best. They can then
22 help us provide those tools, those resources, those
23 educational principles nationally.
24 An example is Ebola. So the first -- when we
25 received the phone call to transport the first Ebola
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1 patient, really very few clinicians, myself included,
2 were familiar with the management of Ebola patients,
3 the transmission of disease, the appropriate
4 protection.
5 We reached out to Alex Isakov at Emory
6 University and the CDC, who is one of our medical
7 directors. His team helped our team nationally put
8 together principles, practices, protocols, educational
9 materials in a very short period of time. He did a
10 nationwide, what we call, E grand rounds. So he did a
11 webinar for our folks nationally on what the Ebola
12 patient population, how it should be managed, and we
13 then made that available to anyone that wanted it.
14 So it allowed us to be smarter and to
15 understand and to be our own resource. We've done the
16 same thing with active shooter and hostile events.
17 We've done the same thing with cardiac arrest
18 management, mobile integrated healthcare. It's a
19 better way, I think, to implement the art of the
20 science.
21 Q. And the information that you're accumulating
22 nationally, is that available to local medical
23 directors?
24 A. So that's available to anyone that wants it.
25 And we made a strategic decision five years ago that
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1 medicine is not proprietary. So they are -- this is
2 all posted on our website. During the Ebola crisis,
3 any organization that wanted our materials could take
4 our materials, search for AMR, replace with the name of
5 their organization. And all we asked was if they had,
6 obviously, better data, then we would upgrade ours. So
7 it is available to anyone that needs it.
8 Q. Do you also have outreach efforts
9 specifically to medical directors working for AMR
10 operations? You just mentioned meeting with the ones
11 in California.
12 A. We do. So we -- if there are specific topics
13 that come up, the most recent being, again, active
14 shooter/hostile events, Dr. Rich Carmona, who is based
15 here in Arizona, is one of our strategic consultants.
16 He's been working with us on the active shooter events;
17 the same thing with Ebola, mobile integrated
18 healthcare, cardiac arrest, and actually things like
19 TXA, which is a drug that's given in trauma patients.
20 Q. Your information, is that available to local
21 operations for benchmarking?
22 A. Yes, it is.
23 Q. And let's say that -- I mean you're obviously
24 the top clinical person at AMR, correct?
25 A. I believe so.
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1 Q. So if somebody running a little operation in
2 Northern Arizona had a clinical question, do they have
3 to go through a chain of command to get to you, or are
4 you directly available?
5 A. So my cell phone is out there everywhere. I
6 am happy to answer directly or to find the right
7 resource.
8 Q. Could you speak for a moment about the
9 evolution of ambulance transport medicine from the
10 19 -- just how medicine used to be done 10, 20 years
11 ago versus how it's done now?
12 A. In EMS?
13 Q. Yes.
14 A. So when I was first getting involved in the
15 late '80s, early '90s, there was a real big focus, as
16 EMS developed, on rapid transport. The concept being
17 that the acutely ill or injured patient needed to be in
18 a hospital setting as quickly as possible.
19 Over the years, with articles like this and
20 exploration into the literature and the evidence, we've
21 identified that there are certain things that require
22 more than rapid transport, or actually don't require
23 rapid transport and may require a focused effort not
24 being transported for stabilization. So the terms we
25 use are stay and play or load and go to identify how to
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1 best manage that patient to maximize their positive
2 outcome.
3 So we've moved from driving fast to a mobile
4 practice of medicine; assessment, appropriate
5 intervention, appropriate risk stratification,
6 intervention and reassessing those patients.
7 Q. And the interval between a patient being
8 loaded onto an ambulance and getting to the facility
9 it's being transported to, is that an important
10 interval?
11 A. That's a very important interval. All the
12 intervals are important. I'll say that. The ambulance
13 transport interval is important because that tends to
14 be a highly -- in the acutely ill and acutely injured
15 patient, that tends to be an intensive time of trying
16 to correct physiology and protect anatomy, so diving
17 deeper into the illness or to the injury and
18 stabilizing that illness or injury.
19 It's also a time to reassess. So what we
20 know in trauma, for example, is that trauma is a
21 continuum, and if a patient deteriorates rapidly, that
22 may be an indication for surgical intervention in and
23 of itself because of the deterioration. So that
24 ongoing reassessment becomes critical in helping to
25 define the next step.
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1 Q. During his examination, I asked Hellsgate's
2 Chief Bathke about his approach and perceptions on the
3 management of sepsis. He testified this is a shock
4 situation that should be approached with oxygen and IV
5 and patient monitoring.
6 Do you agree with that?
7 A. So sepsis is a pretty evolving new concept;
8 probably, I would say, two years now that we've
9 understood sepsis more. It is, interestingly -- and I
10 didn't know this until three or four years ago. It has
11 a higher mortality than patients with STEMI, higher
12 mortality than patients with stroke, higher mortality
13 than patients who have significant trauma. So it is a
14 major life-threat event.
15 The way that we manage sepsis today in most
16 contemporary EMS systems is to identify that the
17 patient potentially has sepsis. If that's the case,
18 then the healthcare system is integrated immediately
19 with that, just like with a STEMI or trauma or stroke,
20 so that they can be prepared to rapidly draw blood
21 cultures, assess what's going on with the patient,
22 stabilize the patient, and get the patient the right
23 antibiotics.
24 There's several things that have changed
25 pretty dramatically in the past six or eight months.
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1 There are systems that are now drawing lactic acid.
2 It's a finding in the blood that may indicate that the
3 patient has an overwhelming infection. There are now
4 systems that are administering antibiotics in the
5 ambulance in the field, again, because of the high
6 mortality. Almost all those patients need very
7 high-volume fluid resuscitation during the initial
8 phases of managing.
9 So it's a pretty -- it's a high mortality,
10 unfortunately, high mortality, but very complex event
11 that's getting a lot of clinical attention
12 internationally.
13 Q. The Chief also told us that Hellsgate
14 benchmarks its EMS employees three ways; quality checks
15 of patient records, annual review of employees, and
16 what I think you EMS folks call tape and chart, a peer
17 review of patient condition, treatment, outcomes, and
18 evaluation of how that went.
19 Can you speak to that?
20 A. Yeah, so obviously, I mean I don't know the
21 processes that Hellsgate goes through. Those are
22 appropriate processes. A lot of EMS systems, we do
23 those things as well; that we review our practitioners,
24 we reviewer our documentation, we review auditory
25 files, anything that we have involved with the patient.
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1 We think, in terms of looking at quality in
2 performance, that's the beginning of an assessment
3 piece. So our benchmarking, we think it's important to
4 really dive down into what happened. Outcomes are
5 important for us, so having an external entity, whether
6 it's a registry or it's a hospital outcome, are
7 important; for example, did the blood vessel get opened
8 in the hospital, did we identify the STEMI
9 appropriately, and then activities related to that that
10 either improve findings that aren't acceptable or
11 communicate those findings that are.
12 Q. So is there a step beyond those three things
13 that your protocols would indicate should be done?
14 A. So we do, in AMR, pretty much across the
15 board, and that's how we get our Things that Matter
16 metrics, we take that, we benchmark that, and then we
17 try and match the literature, the evidence, with what
18 the best practices are and then provide education.
19 So those documents of sudden cardiac arrest
20 that you saw, we actually call those prescriptions for
21 improvement, and they're based on the science, they're
22 based on our review, they're based on the registry, in
23 an effort to improve.
24 Q. And does AMR compare itself, local
25 operations, compare themselves to AMR nationally as a
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1 whole, national providers as a whole? What's the
2 comparison?
3 A. Yes. So we like comparing ourselves with any
4 like practitioners and like circumstances. CARES
5 Registry compares us to EMS systems and healthcare
6 systems across the country.
7 It's important for us in some areas to
8 compare ourselves with a very narrow window. So, for
9 example, in Las Vegas we have two operations in
10 Las Vegas. It's very interesting for us to compare the
11 two different organizations that are geographically in
12 the same place.
13 So we embrace that. We have found in that
14 process that there are areas that need improvement by
15 expanding that net, and that's been really valuable to
16 us.
17 Q. Chief Bathke also told us that when it comes
18 to ambulances, even in the nonemergency, what I'll call
19 interfacility or convalescent setting, faster is always
20 better.
21 Do you agree with that? And more
22 importantly, does the national literature agree with
23 that also?
24 A. So -- and, again, I wasn't here for the
25 testimony, so if okay, I'll express my opinion on that.
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1 There is a lot of discussion about -- and
2 I'll use the term "fast" to be a lights and sirens
3 response to a request for service, if that's a broad
4 enough category.
5 It's pretty clear from the literature that
6 about 10 percent, give or take, depending on the study,
7 about 10 percent of what EMS responds to is an actual
8 life-threatening emergency where patients need an acute
9 intervention. The other 90 percent may still need EMS
10 or need an evaluation, but aren't necessarily in that
11 time-dependent deterioration.
12 One of our biggest challenges nationally in
13 lights and sirens responses are motor vehicle crashes.
14 And so we have to be thoughtful as an EMS system when
15 we send any apparatus, law enforcement, fire, EMS. In
16 a priority lights and sirens scenario, we have to be
17 thoughtful and accountable to the fact that we're
18 creating a little bit more of a chaotic environment and
19 could potentially cause a car crash that could hurt
20 folks.
21 So there is a lot of -- a lot of interest in
22 defining better what needs most rapid and what needs a
23 lower level of response. Our colleagues in Charlotte,
24 North Carolina have published several papers on
25 response intervals and how they -- the 8-minute,
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1 historical 8-minute response interval is not predictive
2 of survival or mortality.
3 That said, my assessment is, no, not every
4 ambulance or engine, or law enforcement for that
5 matter, needs to immediately and rapidly get to a
6 person or patient's side. But every system has to have
7 a way of identifying those that potentially need it and
8 absolutely focus on getting that resource to that
9 patient's side rapidly.
10 Q. With regard to the 90 percent that are not
11 time-dependent, if you have two different ambulance
12 providers and one is theoretically able to arrive
13 30 seconds faster than the other or even a minute
14 faster than the other, will it always be better to use
15 that faster one, or are you going to look at things
16 other than speed?
17 A. So let me make sure I understand your
18 question.
19 Q. Okay.
20 A. So is the question if -- if you have two
21 responding entities, one gets there 30 seconds before
22 the other, would you --
23 Q. Or a minute before the other, is -- in
24 evaluating which one is the preferred responder --
25 A. Oh, I see.
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1 Q. -- is the speed going to be what is most
2 important to you from a clinical aspect?
3 A. Speed is one of the variables, but
4 potentially not the most important variable.
5 The right level of resource has to get to the
6 patient's side. So I'll use the analogy of an academic
7 Medical Center. If a patient in an academic Medical
8 Center needs an emergent surgical intervention, it may
9 be the resident or the fellow, a lower level of
10 training, that gets to that patient's side the fastest.
11 He or she may be there. The patient may need the
12 expertise of the faculty surgeon in order to have the
13 best available outcome for that particular condition.
14 So it is just as important, maybe more
15 important, to have the right trained, competent,
16 equipped entity respond to that patient's side. In the
17 90 percent, where the timing is not as critical in
18 terms of patient outcome, that resource becomes more
19 important.
20 Q. And in the interfacility transport scenario,
21 does faster is always -- let's say you're picking up a
22 patient at a hospital and taking it to another
23 hospital. Does faster is always better apply?
24 A. So I'll answer that with no and a caveat.
25 Q. Okay.
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1 A. So no. As a matter of fact, in the
2 interfacility world it's probably the least important.
3 The caveat is, there are several conditions that make
4 it just as high priority as in the field.
5 So if I happen to be a hospital that
6 identifies a patient that has a STEMI in my Emergency
7 Department and I don't have a cath lab, I'm taking that
8 patient from Facility A to Facility B. Because of the
9 time sensitivity of that heart attack, that patient
10 needs to be moved very, very quickly to be
11 appropriately cared for.
12 But the overwhelming majority of
13 interfacility transports, unless the patient's
14 deteriorating, are not as time-sensitive.
15 Q. Based upon your resumé, you're obviously
16 interacting with other prehospital medical service
17 providers on a regular basis, correct?
18 A. That's correct.
19 Q. What's your perception and opinion about the
20 quality of the AMR organization's attention to clinical
21 excellence in that context?
22 A. So I'm obviously very biased, but I feel very
23 strongly, and it was a big part of my decision to join
24 the organization in the first place. I feel very
25 strongly that the AMR attention to clinical
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1 performance, excellence, and accountability is probably
2 the best in an EMS system I've seen.
3 I would support that with the fact that our
4 numbers, our metrics, our performance, again, good, bad
5 and ugly, is open for folks to see. We put our cardiac
6 arrest survival rate in our RFPs, and there are some
7 communities nationwide that exceed and there are some
8 that do not; but we feel very comfortable with our
9 approach at managing our clinical care and our
10 performance.
11 And probably just as important, two years ago
12 we launched a just culture initiative. A just culture
13 initiative basically says we don't -- we don't
14 discipline or penalize for clinical issues. We'll
15 remediate. We want our folks to bring up questions,
16 challenges, problems, so that we can make things
17 better.
18 So I -- your question about our clinical
19 care, I'm extraordinarily proud of it. We have reams
20 of data that can support an assessment or an assumption
21 on my part objectively, and I think the organization
22 really prides itself in being in the clinical arena.
23 MS. FICKBOHM: I don't have any other
24 questions for this witness, Your Honor.
25 ALJ SHEDDEN: All right. Mr. Ray, do
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1 you have any questions?
2 MR. RAY: Yes, I do.
3
4 CROSS-EXAMINATION
5 BY MR. RAY:
6 Q. Good morning, Doctor.
7 A. Good morning.
8 Q. So the applicant in this case is a first
9 responder, first on the scene the high majority of the
10 time, and they have applied to do the ambulance service
11 as well.
12 Does AMR have any first responder assets or
13 resources in Arizona, that you're aware of?
14 A. I would defer to one of my Arizona
15 colleagues. I don't know specific.
16 Q. So nationally they do?
17 A. So I was going to answer nationally, we do.
18 Q. Okay.
19 A. So we do in a variety of different ways. So
20 with our acquisition of Rural/Metro, obviously, we have
21 fire apparatus with medical responders in some
22 communities. We, in a multitude of communities, will
23 use non-transport vehicles to first respond. We also
24 will use transport-capable vehicles, who will respond,
25 but not transport unless necessary. So we have a
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1 variety of different components.
2 Q. Okay. One of the issues that has been raised
3 as part of the application is the need for continuity
4 of care between the first responder on the scene and
5 the later arriving --
6 A. Right.
7 Q. -- in normal circumstances, the ambulance
8 service.
9 Has AMR studied that issue on a national
10 perspective?
11 A. So I would -- if I can, I'll bump it up to
12 our parent, Envision Healthcare. So Envision
13 Healthcare includes EmCare Physician Practices, most
14 recently another group, Sheridan. So we have emergency
15 physicians, critical care physicians, surgeons,
16 hospitalists. We have ambulances, obviously. In some
17 states we have prehospital nurses. We have the
18 communications center. So the issue within our own
19 walls becomes an issue of discussion of making sure
20 that transition or handoff of patient care in our own
21 organization is done appropriately and correctly.
22 So your question is spot on, which is we know
23 from the medical literature, and Joint Commission makes
24 a big deal, appropriately, of making sure that if one
25 provider hands a patient off to another provider, the
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1 right communication, the right handoff is provided to
2 assure that patient's safety.
3 Any patient in emergency services goes
4 through several, gazillions of handoffs. So,
5 theoretically, the handoff is from the 911
6 communication specialist, who is doing prearrival
7 instructions, to first response to ambulance to the
8 Emergency Department triage nurse to the Emergency
9 Department physician, to the surgeon, to the
10 radiologist, to the ICU.
11 So everyone in medicine, everyone who pays
12 attention to your question in medicine knows that those
13 handoffs are important and it's an important part of
14 clinical practice. They'll never go away and they're
15 always going to be there, which is why we focus on them
16 within our own organization. So...
17 Q. So what -- so let's assume that you have a
18 scenario like we do here in Gila County, where we have
19 a Fire-based EMS first responder, who gets on the
20 scene, initiates assessment, care, treatment, and then
21 needs to transfer that patient to an ambulance service
22 that arrives subsequent to the first responder.
23 A. Uh-huh.
24 Q. So you've got two different organizations
25 treating the patient at this stage of the continuum of
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1 care.
2 Do you have any statistics that would suggest
3 that results in a higher continuity of care issue than
4 if you had a unified employer; i.e., the first
5 responder and the ambulance service are one and the
6 same?
7 A. So I am -- and help me if I don't answer your
8 question directly.
9 Q. Sure.
10 A. I am unaware of any document, publication
11 that's demonstrated that the employer or the agency of
12 record or the entity that is responsible for the
13 practitioner, that a difference in employer or agency
14 or organization has a negative impact at a handoff in
15 patient care.
16 And I would take that all the way up to
17 the ICU, because those same questions are asked in
18 the hospital, where an emergency physician would
19 hand off to a critical care physician, so does it
20 make a difference if the emergency physician is an
21 EmCare physician and the critical care physician is
22 the hospital physician. So we are unaware of any
23 literature that suggests that there is a worsening
24 of patient outcome or patient care in that
25 scenario.
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1 That said, that goes along with the same
2 focus, which is all of us in medicine, regardless of
3 where we are, have to focus on that transition. So if
4 I'm one organization, if it's Acme Emergency Healthcare
5 and I'm the dispatch, I'm first response, I'm the
6 Emergency Department, I'm Acme, those same transition
7 issues are between two practitioners. So if you're
8 Acme first response and I'm Acme ambulance, you and I
9 have the same accountability and responsibility.
10 And I would take it one step further, which
11 our medical colleagues do in the hospital, which is if
12 a patient is critical enough or unstable enough to
13 require additional resources, hands, or to have the
14 emergency physician travel with them up to the
15 operating room, as opposed to the nurse, the collective
16 interaction of that team and working together and
17 saying, "I'm going with you" or "You come with me," all
18 focused on what the patient needs, is what helps
19 decrease any change in mortality in that patient.
20 Q. Okay. You did answer my question. So
21 congratulations. It was a long question.
22 A. And a long answer.
23 Q. So does AMR have specific training protocols
24 that it establishes at a national level and pushes down
25 to, for instance, ambulance providers that says you
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1 have some critical elements to establish good
2 continuity of care and these are our recommendations?
3 Does AMR do that?
4 A. So we do, and we have -- as part of our
5 Things that Matter initiative, part of -- part of our
6 recent addition was the patient documentation piece, so
7 the patient continuity piece, making sure that
8 information we either get from families or get from
9 other organizations is managed by us and then
10 subsequently appropriately communicated to the
11 receiving facility. So it's part of our patient safety
12 initiative, part of the Things that Matter component of
13 what we do.
14 Q. Okay. Does training -- would training
15 between first responders who are not the same
16 employer-based entity as the ambulance service, would
17 that improve -- is there any data, research that
18 suggests that improves patient outcomes or lessens
19 continuity of care issues --
20 A. So I am --
21 Q. -- on a national level?
22 A. Sorry. So I'm -- I know that that probably
23 exists. I am not prepared to be able to tell you what
24 those documents are. But I will say that I think the
25 general sense in medicine as a whole, public safety
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1 medicine specifically, is that joint training, joint
2 education, joint drilling, joint exercises always,
3 always, always improves our ability to respond together
4 and effectively with a patient.
5 There's a subtlety in there that I think is
6 also important, which is, there are sometimes tensions
7 between organizations. The fact that we're in meetings
8 like this, there are tensions between organizations
9 that sometimes could be very harmful at a patient's
10 side if those same tensions impacted patient care.
11 So if you and I train together, I get to know
12 you more, I get to understand that what we do is fairly
13 similar, we have different challenges, but we develop a
14 relationship that's better.
15 September 11th did that for public safety
16 across the board. And if you look back at what we do
17 with law enforcement and fire and EMS and the
18 healthcare system, we are much better buddies. We
19 trust each other. We focus on things that we never
20 focused on before because of the fact that we had to
21 get together to train together to understand to do our
22 jobs, what our patients expect us to do.
23 Q. All right. Thank you, Doctor.
24 A. Thanks.
25 MR. RAY: I don't have any other
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1 questions. Thanks.
2 ALJ SHEDDEN: Let me ask, Mr. Meyerson,
3 you're going to have questions, I assume?
4 MR. MEYERSON: Yes.
5 ALJ SHEDDEN: All right. Why don't we
6 take our break, and that way you'll not be interrupted.
7 We're about four minutes of. Why don't we meet back up
8 at about 11 or 12 after 10:00, in 15 or 16 minutes.
9 (A recess was taken from 9:56 a.m. to
10 10:11 a.m.)
11 ALJ SHEDDEN: All right. We're back on
12 the record. I don't know if you've met Mr. Meyerson,
13 the attorney for Hellsgate.
14 THE WITNESS: Good morning.
15 ALJ SHEDDEN: But I'm going to turn it
16 over to him for whatever questions he has.
17
18 CROSS-EXAMINATION
19 BY MR. MEYERSON:
20 Q. Good morning, Dr. Racht.
21 A. Good morning.
22 Q. Can you tell us whether you specifically
23 provided services for CON 58?
24 A. So me, specifically?
25 Q. Have you specifically provided services
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1 directly to CON 58?
2 A. So as part of our national initiative?
3 Q. No, directly for CON 58.
4 A. Have I practiced in --
5 Q. Correct.
6 A. No, I have not.
7 Q. Have any of your previous positions been
8 focused exclusively in Arizona?
9 A. No, they have not.
10 Q. Do you have any direct input on the
11 operations and services provided by CON 58?
12 A. Yes, I do.
13 Q. Where you are talking to operators on the
14 ground in CON 58?
15 A. So let me make sure I understand your
16 question. By "operators on the ground," clinical --
17 Q. The EMTs and paramedics on the ground in
18 CON 58.
19 A. Actually out on patient care?
20 Q. Correct.
21 A. No, I do not.
22 Q. What do you know about Arizona's treat and
23 refer program?
24 A. The treat and refer initiative?
25 Q. Yeah.
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1 A. So the initiative, the treat and refer
2 initiative, is an initiative by the State as part of a
3 mobile integrated health approach. I think it's the
4 beginning of a pretty innovative, actually, initiative
5 to look at a different level of care.
6 Q. And has Life Line CON 58 filed for an
7 application specifically for that treat and refer
8 program?
9 A. I would have to defer to the Life Line
10 leadership.
11 Q. Have you -- isn't it true that you've never
12 attended an ADHS treat and refer meeting, have you?
13 A. No, I have not.
14 Q. In CON 58 there's a HALO program. Are you
15 aware of that?
16 A. No, I am not.
17 Q. And what is your current board certification?
18 A. Medicine, internal medicine.
19 Q. Would you agree with me that you've never
20 been certified as an emergency room physician?
21 A. That's correct.
22 Q. Agree with me that you've never been
23 certified in Arizona as a physician?
24 A. That's correct.
25 Q. Isn't it true that every one of the programs
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1 you testified about, that no one from CON 58 has
2 actively participated in those programs?
3 A. I don't know that that is correct.
4 Q. But you don't have any evidence that would
5 show that they have?
6 A. I don't have evidence one way or the other,
7 correct.
8 Q. Are you aware of CON 58, has anything been
9 done about -- with the initiative you talked about in
10 reference to obtaining blood cultures or administration
11 of antibiotics?
12 A. I don't believe that's the case. Again, I
13 would defer to their leadership if they have had local
14 discussion about that.
15 Q. Can you re -- you've mentioned the Medical
16 College in Wisconsin. Can you -- do you remember what
17 you said about the Medical College in Wisconsin? I
18 think --
19 A. I don't believe I've mentioned that --
20 Q. Oh, you did not?
21 A. -- in testimony.
22 Q. Are you aware of the Medical College in
23 Wisconsin?
24 A. So I have had -- I just had social discussion
25 with the Chief about Medical College of Wisconsin
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1 off --
2 Q. Correct. And you know of some of the
3 physicians that are there?
4 A. Yeah, I do.
5 Q. And would you agree that they have a very
6 high level of contribution to the EMS conversation
7 nationally?
8 A. So I'm not sure I understand you.
9 Q. Well, are they a leading contributor to the
10 EMS standards of care and innovation nationally?
11 A. So there are several clinicians at the
12 Medical College of Wisconsin who have done a lot for
13 emergency medical services and have contributed a lot
14 to the evidence in the literature.
15 Q. You testified about community paramedicine
16 and actually went over community paramedicine quite a
17 bit in your testimony. Would you agree that a
18 community paramedicine program requires an availability
19 of resources to be successful?
20 A. Yes, I would agree.
21 Q. Would you agree with me if I said if a
22 provider is already relying on another provider outside
23 its system, that it would be difficult for that
24 provider to successfully operate a community
25 paramedicine program?
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1 A. I would not agree with that.
2 Q. You would not agree that if a resource --
3 from a resource standpoint, they don't have enough
4 resources to serve their own CON operationally, that it
5 would be difficult to implement a community
6 paramedicine program?
7 A. So I would not agree with that.
8 Q. Okay.
9 A. Can I --
10 Q. No.
11 A. -- expand?
12 Q. Would you agree with me that the challenges
13 facing community paramedicine are the same across the
14 country?
15 A. I would not agree with that.
16 Q. You testified earlier that there are a number
17 of community paramedicine issues and that they are
18 being addressed nationwide and looked at nationwide.
19 The challenges are not the same, necessarily, on a
20 micro level; but on a macro level, are they the same?
21 A. So maybe I'm -- and I apologize if I
22 misunderstood your question. So what I responded to
23 was the last part of your question there. So the
24 challenges are not the same in each individual
25 community, but there are some global challenges which I
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1 think impact all programs.
2 Q. But you would agree that available resources
3 are an important part of that program for any of those
4 communities?
5 A. So any mobile integrated healthcare or
6 community paramedicine program has to have the
7 resources that are specific to that program in order to
8 provide that care. Those resources aren't necessarily
9 the same resources as the emergency response resources.
10 Q. Would you agree with me that the research on
11 the mobile integrated health has little impact on the
12 current provision of services being provided by Life
13 Line in CON 58?
14 A. Could you clarify your question a little
15 more?
16 Q. Yeah. There's a lot of research, and we saw
17 a lot of research on the exhibits, about community
18 paramedicine or mobile integrated healthcare. And my
19 question is, does it directly impact the current
20 services being provided in CON 58?
21 A. So a direct impact today, no. The
22 implication of mobile integrated healthcare in any
23 community, including this community, could have an
24 impact on patient management and strategy.
25 Q. And that goes to your comment about our
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1 families for years to come will shape the mobile
2 integrated healthcare model.
3 A. Right.
4 Q. But it still comes down to the resources with
5 a certain community to be able to provide those
6 services?
7 A. Correct.
8 Q. The infographic, I'm going to pull up 3ee
9 that was shown. Does it kind of go out of order?
10 Yeah, okay, there it is.
11 3ee, this infographic, is this something
12 that's produced by AMR?
13 A. Yes, it is.
14 Q. Is that infographic something that I, as a
15 consumer, would be able to access through the website
16 or other means?
17 A. I don't know specifically if it's available
18 on the website, but its intent is that it's -- it is
19 accessible.
20 Q. You said it's a reminder to employees of AMR
21 that we need to maintain a high level or high quality
22 of care to see all of these numbers. But you would
23 have to agree with me that this exhibit actually talks
24 more to the size of the company. It really says
25 nothing on here about quality of care.
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1 A. So the intent of this, in my use of this
2 infographic, is to remind all of our practitioners of
3 our size and how important it is for us to be
4 accountable and to provide care that's appropriate
5 because of the huge impact that we have. So this is a
6 motivator of sorts, I guess, and a reminder that we
7 have a big responsibility.
8 Q. So this is sent out to your paramedics and
9 EMTs on a monthly basis as a reminder?
10 A. No, it's not.
11 Q. Would you agree with me that the CPR training
12 program that was mentioned -- and as you were talking
13 about it, I didn't write down it fast enough, but
14 there's the -- we'll go with the 3t. I think this is
15 kind of the same idea.
16 There was one that was done in May of 2016.
17 Would you agree with me that that CPR training was not
18 provided in CON 58?
19 A. I would have to defer to my colleagues in
20 that organization.
21 Q. And I'm going to open up a couple of other
22 exhibits that were used. These standard handoffs, you
23 would agree that these address transfer of care of a
24 patient to another -- either a facility or another
25 entity of some kind?
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1 A. This particular document is a very specific
2 population, which is the highly infectious Ebola
3 patient population.
4 Q. And the next one here --
5 ALJ SHEDDEN: I'm sorry, let me just
6 jump in. That was 3ff we were just looking at.
7 MR. MEYERSON: Yeah. Sorry.
8 BY MR. MEYERSON:
9 Q. And 3gg as well is this -- but it's again
10 talking about transfer of care from one entity to
11 another?
12 A. That's correct.
13 Q. And would you have developed these studies if
14 transfer of care wasn't a concern?
15 A. Well, this is a very specific patient
16 population, so the concern that led to this initiative
17 and this documentation is that this is a different --
18 this is a different approach to transferring a patient.
19 This isn't a standard patient transfer. This is
20 outside of what we do day-to-day. It requires very
21 specific and different logistical approaches, and it's
22 a higher risk population because it can create harm to
23 the rescuers themselves. So this is very specific to
24 the highly infectious patient population.
25 Q. But you have written protocols within AMR
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1 regarding transfer of care from ambulance to ambulance
2 or ambulance to healthcare facility; they're written
3 protocols that are provided to your paramedics and EMTs
4 and that are expected to be undertaken when they
5 transfer a patient, correct?
6 A. So every AMR practice nationwide, their
7 medical director will develop those protocols, in
8 concert with the leadership in that organization, and
9 address those things that are specifically required by
10 the medical director or by State regulatory entities or
11 by that individual practice.
12 Q. So the answer to the question is, yes, there
13 are written protocols?
14 A. So we have in many of ours -- again, we're in
15 thousands of communities, so we do have written
16 protocols that address transfer of patients from one
17 entity to another.
18 Q. So there's care taken to minimize the impact
19 of the transfer of care between each healthcare system,
20 let's say, that is included in that transfer?
21 A. Yeah, so I think the focus is, there is an
22 effort to make all providers aware of how to facilitate
23 that transfer in the most appropriate way.
24 Q. And you would have to agree that to some
25 extent, every transfer of care creates another level of
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1 potential miscommunication between providers and could
2 impact patient outcomes?
3 A. So every transfer of a patient from one
4 practitioner or one caregiver to another has the
5 potential to impact care, both negatively and
6 positively. So there's also the opportunity to ask
7 questions, reassess, did you do this, did you do that.
8 So, yes, there is that risk, and that's what
9 we focus on. Your previous question is very important,
10 but there's also the opportunity to go through and to
11 confirm, much as happens in the aviation industry, to
12 confirm that certain things were or were not done.
13 Q. You mentioned a specific condition -- I can't
14 remember what it was. I was trying to write it
15 down. -- that was a benchmark for overall service
16 delivery. Was it a --
17 A. Cardiac arrest.
18 Q. Okay.
19 A. Right.
20 Q. And it was your testimony that the response
21 time in that situation is a critical aspect of a
22 patient outcome; is that correct?
23 A. So it is critical that -- in that particular
24 patient population, it's critical that the right
25 resources get to the patient's side quickly. So that
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1 may be -- in many communities that's a bystander
2 resource with an app that will send an individual who
3 knows how to do chest compressions. It may be a
4 publicly available AED. It may be a first responder
5 defibrillator. It may be a law enforcement
6 defibrillator. It may be an ambulance defibrillator.
7 But it is critical to get the right level of care to
8 that patient as quickly as possible.
9 Q. So the question I would have then is, the
10 time from the call to getting to the patient is
11 critical, whether it's a bystander -- I mean presumably
12 the bystander isn't receiving the dispatch call.
13 A. Right.
14 Q. But --
15 A. It would be interesting if they were.
16 Q. But --
17 A. Your next --
18 Q. -- what we're saying is, essentially, that
19 the time of the occurrence of the heart attack to the
20 point where the first person can get there is critical
21 to the patient outcome?
22 A. That's correct.
23 Q. There were 3w, x, y and z. So I'll just pull
24 up one of these, because I think they're in subsequent
25 years. I'll pull up the latest one just for our
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1 purposes. So this is Life Line Exhibit 3z, and these
2 are the cardiac arrest facts. And then down below
3 there's the national group data and the comparison of
4 how AMR as a whole did compared to the national group
5 data.
6 How does CON 58 compare specifically against
7 those benchmarks?
8 A. I don't have their specific data to compare
9 to there at this point.
10 Q. There was also studies that determined
11 protocol and we talked about benchmarking, and
12 Ms. Fickbohm said that the Chief testified the three
13 ways that they benchmarked, and then asked you if
14 anything beyond that was something that AMR did. And
15 you mentioned that you would go another step and do
16 studies to determine whether or not protocols needed to
17 be changed or addressed.
18 Aren't those really addressing -- that's not
19 really benchmark. That's what you're doing with the
20 benchmark information, correct?
21 A. So I'm sorry if I didn't convey that
22 appropriately. So the additional evaluation of that
23 data, so once we review charts, review -- have the
24 data, the evaluation of that data, looking at that data
25 will help us determine what we need to do moving
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1 forward.
2 So let me make sure. I'll try and describe
3 it, and please tell me if I don't.
4 So there's studying our own data, which is
5 looking at our own data, which is taking this and
6 saying if our -- if our bystander CPR rate is low and
7 our survival in the Utstein bystander CPR category is
8 low, there's a clear message there. And the clear
9 message is, we've got to focus on bystander CPR to
10 improve survival.
11 It's not a study. So we wouldn't do, for
12 example, a research study to look at -- we would use
13 evidence from studies to guide this, but we wouldn't
14 initiate a research study routinely from that kind of
15 information. So it's evaluating the data, looking at
16 what that data means, and then sorting through the most
17 appropriate way to improve on the patient management
18 side.
19 Q. But you would agree that --
20 MS. FICKBOHM: Excuse me, Counsel. I
21 just want to have clarity of the record that when
22 Dr. Racht was just giving his answer, he was pointing
23 to the exhibit that's up in front of all of us,
24 Exhibit 3z, LLA-3z, just for clarity of the record.
25 Thank you. Sorry to interrupt, Counsel.
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1 ALJ SHEDDEN: All right.
2 BY MR. MEYERSON:
3 Q. But this is all on a national level. You're
4 collating massive amounts of data for a national review
5 of protocols, not specifically CON 58; would you agree
6 with that?
7 A. So let me describe, which may help. So from
8 a national perspective -- and I think you'll hear
9 testimony in a little bit about some of our other
10 metrics that we gather at a national level and then
11 provide to the local level.
12 So from a national perspective, our data, our
13 overall care survival is the benchmark of all of AMR,
14 everything else. All of our other performance metrics,
15 so relief of pain, Trauma Center destination time
16 intervals, those data elements, we have that on a
17 national level to benchmark, and then each individual
18 practice has their ability to look at what their
19 performance is and compare it to this.
20 Based on that, we can provide national
21 resources. Dr. Betz, the local medical director, can
22 go in and make changes in the protocol, processes, or
23 education. Our folks can do that. We provide, for
24 example, for this, a national -- series of national
25 webinars that go through educational approaches to be
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1 able to guide and direct this.
2 So the national supporting structure is
3 similar, in a way, to the advanced cardiac life support
4 program from AHA. It's developed nationally, but it's
5 administered at the local level.
6 Q. So how, specifically, has it been
7 administered at the local level in CON 58?
8 A. So, again, I would ask those questions of the
9 local leadership for the specific details on that.
10 Q. You said that the rapid response model is no
11 longer the model for 911/emergency calls?
12 A. So let me clarify. I don't believe I said
13 that. I said or responded that responding,
14 essentially, lights and sirens as rapidly as you can to
15 every request for service is no longer the perceived
16 model.
17 Q. But there are some indications or some
18 conditions and emergencies that response time --
19 A. Oh, absolutely, and I think I testified to
20 that, that there were conditions that require that very
21 quickly.
22 Q. There was some questioning that Ms. Fickbohm
23 asked and mentioned about Chief Bathke's testimony on
24 treatment of sepsis, and were you here for his
25 testimony on that?
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1 A. No, I was not, and I believe I tried to
2 convey my opinion on that and not to comment on any of
3 the previous testimony that I was not there.
4 Q. So you weren't trying to criticize Chief
5 Bathke's response?
6 A. Not at all. I was trying to specifically lay
7 out what our response would be to that, and I tried to,
8 hopefully, make that very clear. I was commenting on
9 our approach.
10 Q. On the benchmarking, the three items, there
11 was a comment by Ms. Fickbohm about the outside entity
12 and whether there's a review with an independent third
13 party.
14 Were you here for Chief Bathke's testimony on
15 how they do their benchmarking?
16 A. I have not been here for any of the Chief's
17 testimony.
18 Q. So his comments about having the other
19 facilities and working with the hospital to assist with
20 the outcomes and reviewing the actual outcomes of
21 certain transports, would you understand that, if he
22 had mentioned that, would you understand that to be an
23 independent third party going through and reviewing
24 specific outcomes?
25 A. Yes, so I believe -- and, again, I wasn't
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1 here for the testimony; but if the hospital or
2 healthcare system is a participant in reviewing the
3 care independently, that that is an appropriate
4 approach.
5 Q. There were a lot of studies that you pointed
6 to or that your counsel -- that counsel pointed to that
7 you've been involved in, and I certainly applaud
8 anything that improves the healthcare system. Is that
9 information available to the general public?
10 A. So that information on our -- either on our
11 website, if those are appropriate documents, are. That
12 information is also available in a variety of venues,
13 so through the National Library of Medicine, through
14 the individual journals, through whatever the
15 individual publication uses to make that available.
16 Q. And do EMS Associations, let's call them,
17 ever use those studies to provide training at
18 conferences or seminars?
19 A. Yes.
20 Q. And so the general public, including
21 Hellsgate and its staff, could attend those and
22 implement those protocols into their own procedures at
23 the local level?
24 A. That is correct.
25 Q. You stated that 10 percent of interfacility
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1 transports are -- would be life-threatening. Would you
2 agree with me that that number is highly dependent on
3 the number of hospitals or healthcare facilities within
4 a certain community?
5 A. So let me clarify. I believe I testified
6 that 10 percent of 911 calls are life-threatening. I
7 don't know what the number of interfacility
8 life-threatening calls are. I don't know that the
9 literature knows that.
10 Q. Okay. I thought you testified that a vast
11 majority of interfacility transports can wait a long
12 period of time and have no impact on patient outcomes.
13 A. So I did testify to the fact that there are a
14 large number of interfacility transports, and we
15 provide tens of thousands of them per year, that don't
16 require the same time sensitivity, that same rapidity.
17 Q. But you don't have any data to support the
18 large number?
19 A. Other than experience, correct. That's
20 correct.
21 Q. So going to the interfacility transport then,
22 the large number that you just described, would you say
23 that in a situation or in a community where there are
24 many hospitals, that interfacility transports for
25 critical care needs because one hospital can't provide
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1 a certain service, so they need to transfer to another
2 hospital, are far less than a community where there's
3 one hospital that doesn't have the highest level of
4 trauma care?
5 A. So it would be intuitive to me, I think, to
6 say that if there are -- in an urban environment, with
7 higher levels of care facilities, the availability of
8 critical care resources would be greater than in a
9 rural or a suburban environment in that regard. So I
10 don't know that I can comment specifically, but it
11 intuitively makes sense that if you have a density of
12 resources, there's going to be more availability.
13 Part of the component of interfacility
14 critical care transports and time dependency, and I
15 think it's important in any system that all of us are
16 participating in, is, a hospital is considered a stable
17 place for a patient. It might not be the right stable
18 place for a patient.
19 So there are patients who are sick that need
20 to go to a different level of care. There are patients
21 that are sick or injured that need go to a higher level
22 of care with a time-dependent problem, and that's, I
23 think I referred to, if a STEMI comes into a facility
24 that doesn't have a cath lab, that's a quick, high
25 acuity that needs to go to a higher level of care.
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1 Q. And so the response time in that case would
2 be extremely important?
3 A. Correct.
4 Q. There was a -- and I'm going to ask you to
5 clarify, because I was writing quickly. There was a
6 comment that you made about the survival and mortality
7 rates not being impacted by response times, and I
8 missed the setting that you were talking about. Can
9 you remind me of that?
10 A. Absolutely. So Dr. Tom Blackwell, who at the
11 time was the medical director of Medic in Charlotte,
12 North Carolina, did a series of studies on response
13 intervals and outcomes in the Medic system in
14 Charlotte, North Carolina. And what they were able to
15 demonstrate in those studies was, through a range of
16 3 to 4 minutes of a difference in response interval,
17 there was no statistically significant impact on
18 mortality.
19 So many in medicine and in public safety
20 medicine use those studies to look at the ambulance
21 transport time. Now, remember, this is the ambulance
22 piece, not the initial responding entity. But they
23 used that to evaluate which response interval is most
24 appropriate. So --
25 Q. And was -- I'm sorry. Go ahead. You --
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1 A. So we don't know -- in EMS medicine we don't
2 know -- as a profession, we don't know what the ideal
3 response interval is for the ambulance to get to the
4 patient's side.
5 We do know that the ideal response interval
6 to get a defibrillator, compressions, hemorrhage
7 control, airway management, those things to a patient's
8 side is as short, rapid and fast as we can. And we
9 often do that with engines, police cars, QRVs, quick
10 response vehicles, and ambulances in that community.
11 Q. So the context, I guess, to summarize my
12 question based on that information, which was very
13 helpful, is, so we're talking about a 911/emergency
14 call, not interfacility transports?
15 A. That's correct.
16 Q. Okay. In that case then, we're talking about
17 a 3 or 4-minute difference creating a statistically
18 significant difference in outcomes in an emergency
19 call; is that correct?
20 A. So I would --
21 Q. Is that what the study said?
22 A. So I would reverse it --
23 Q. Okay.
24 A. -- and say in that 4 -- and I apologize, I
25 don't have the paper in front of me; but in that
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1 4-minute difference in response interval, there was not
2 a significant difference in patient outcome.
3 Q. So do we know then the number of minutes
4 where it would be significantly impacted?
5 A. So that's the question that everyone in EMS
6 struggles with, and those studies were designed to
7 start evaluating that exact issue. And so as I just
8 alluded to, we don't know what the ideal response
9 interval is from the ambulance perspective side.
10 Q. So if we don't know what the ideal response
11 time interval is, wouldn't it make sense that we want
12 to respond as quickly as possible?
13 A. So if resources weren't an issue, if patient
14 safety wasn't an issue, if there weren't motor vehicle
15 crashes, if we didn't want to pay attention to whether
16 I could take an ambulance and move it to a higher -- or
17 an engine, for that matter, a higher acuity call, it
18 wouldn't be an issue; but all of those things are
19 important to a community. So just as surgeons who are
20 on call who have a surgical backup schedule and the
21 anesthesiologist, based on their cases, all those
22 moving parts have to be able to be functional.
23 If an EMS system could simply -- could
24 improve patient outcome and do it with the right
25 community resources by going hot, lights and sirens, as
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1 quickly as possible, closest ambulance to every single
2 call, every community in the United States would be
3 doing that. There are almost none that do that now.
4 There are very few that still respond to every request
5 for care through 911 with a lights and sirens response.
6 So that's changed substantially over about the past
7 five years.
8 Q. So I wasn't suggesting that an ambulance go
9 10 miles per hour faster in order to get there.
10 A. Right.
11 Q. I was saying that if you had a model where --
12 and using the same assumptions, you had a model where
13 the response was X and then you had a model where the
14 response -- based on the same assumptions, but you had
15 a model where the response was X minus 3 minutes,
16 wouldn't it be preferable, with all things being
17 roughly the same, that the X minus 3 minutes would
18 provide better outcomes? Or not necessarily provide
19 better outcomes, but because we don't know what the
20 appropriate response time is, if it's 3 minutes faster,
21 that that would be better?
22 A. So I'll answer -- I hope I'll answer, and if
23 I don't, let me know. I'll answer based on emergency
24 medicine, trauma surgery and what they've done. So
25 it's the same principle as you've described. So you
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1 have -- you have an unknown, but acutely evolving
2 patient.
3 So the Emergency Department doors open. You
4 have ambulance traffic. You have walk-in patients who
5 are all coming in. Ideally, per your analogy -- and I
6 don't disagree with this. Ideally, it would be great
7 to have as many rooms in that Emergency Department as
8 you needed to have, to have as many physicians
9 available so that when you came in, I would see you, as
10 a physician, first. We'd sort things out. We'd get
11 you over to one of six CT scanners quickly. I mean you
12 get my analogy.
13 Q. Yeah.
14 A. So from a utopian standpoint, if we could get
15 every patient into an acute treatment room with a
16 physician right away, get them imaged, I don't think
17 anyone would disagree with the fact that that was --
18 certainly felt better to the patient.
19 The flip side is the CEOs, the insurers,
20 everybody else on the planet, the logistics folks,
21 would say that's impossible for us to do. We can't
22 make that work. And even when we do, there will be a
23 day that one more patient will come in and we're one
24 room short. So we have to figure out -- and we're one
25 doctor short. So we have to figure out how to best
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1 manage them.
2 So I think EMS, like emergency medicine, like
3 trauma surgery, has done a pretty nice job of trying to
4 understand what the potential acuity is and match our
5 resources, system resources, engines, ambulances, quick
6 response vehicles, match those resources to what the
7 patient may need based on our ability to predict that
8 and based on our ability to quickly change midstream
9 and get a resource to someone that needs that resource
10 quickly if their condition changes.
11 Q. So that's a very real-world example, and I
12 guess I want to go back to my question specifically,
13 which is, not knowing specifically whether a response
14 time at X or X minus 3 minutes is going to impact the
15 patient's outcome in a particular situation, would
16 we -- can you agree with me that the X minus 3 minutes
17 would be preferable?
18 A. So it's a hard question to answer, right,
19 because you want me to answer in a --
20 Q. I do want you to answer.
21 A. -- in a box. And I'm going to try, all
22 right. I'm going to try and answer in the box.
23 So I think anyone, myself included, would
24 agree that if everything else was equal, that someone
25 being at my side that was equally qualified as the
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1 other entity that got there earlier, I would want that,
2 and the community would want that.
3 In the scenario that's described, there's so
4 many things outside of that box that influence that,
5 that it could actually not give us the desired result.
6 So if I had -- back to my analogy, the box
7 would be do I get to see my physician quickly. If in
8 that community I have to bring ophthalmologists in to
9 see the patient, then I've not -- they've seen a
10 physician, but I've not necessarily given them the
11 right level of care. And I know it's a weird part of
12 the analogy, but I just want to make sure I'm answering
13 the question based on what you need; but it is a
14 boxed-in question.
15 Q. Okay. Well, let me tweak the question
16 slightly.
17 If the ambulance unit that is coming at
18 X minutes is coming without a paramedic, and the
19 ambulance that's coming at X minus 3 minutes is coming
20 with a paramedic, and assuming whoever's on board is
21 qualified in their positions, but there's a paramedic
22 on the one arriving sooner, which ambulance would you
23 prefer to get to you quicker?
24 A. So I promise I'm not trying to dance around
25 your questions. Our colleagues in the Houston Fire
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1 Department have published data suggesting that too many
2 paramedics is actually harming our patients, in the
3 literature. So the concept of skill dilution; it
4 depends on what that paramedic is doing. We know that
5 EMTs have a specific role. We know that paramedics
6 have a specific role. There are circumstances where
7 either an EMT or paramedic may not be the right person
8 for the patient's needs.
9 So if they were both equal, again, to your
10 question, I would want one that was there more rapidly.
11 I think anyone would.
12 Q. Okay. That study that we were just talking
13 about talked about mortality and survival rate,
14 correct?
15 A. Which study? I'm sorry.
16 Q. I think it was the study about 3 to
17 4 minutes --
18 A. Tom Blackwell's.
19 Q. -- whether it impacts survival or mortality.
20 A. Correct.
21 Q. But there are other things that you can
22 measure besides whether the patient dies or not,
23 correct?
24 A. That is correct.
25 Q. Would you describe to me the joint training
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1 programs that AMR has implemented in CON 58?
2 A. Joint training programs, joint between AMR
3 providers and other providers?
4 Q. Correct.
5 A. I would, again, defer to the operational
6 folks in that CON.
7 Q. Okay. Thank you, Doctor. I appreciate
8 it.
9 A. Thanks.
10 ALJ SHEDDEN: That's it?
11 MR. MEYERSON: That's all I have, yeah.
12 ALJ SHEDDEN: Ms. Fickbohm, any
13 follow-up questions?
14
15 REDIRECT EXAMINATION
16 BY MS. FICKBOHM:
17 Q. I need some acronyms clarified here.
18 ADD, capital A, capital D, capital D, you
19 referenced that in talking about cardiac arrest, I
20 think.
21 A. Yeah, so ADD is attention deficit disorder.
22 Q. Besides that.
23 A. I think I said AED.
24 Q. Thank you. My notes are bad.
25 A. Which is automated external defibrillator.
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1 Q. That's exactly what it was, because I was
2 wondering what ADD had to do with it.
3 A. My ADD doesn't allow me to pronounce the E as
4 appropriate.
5 Q. You referenced to training done by AHA. Is
6 that the American Heart Association?
7 A. American Heart Association, correct.
8 Q. When you were asked about resources for
9 allowing implementation of a mobile integrated
10 healthcare program, all of that is going to take
11 significant cash above and beyond and separate and
12 apart from the ambulance transport operation, correct?
13 A. So it is our experience in all of our mobile
14 integrated healthcare programs that it is a substantial
15 investment, and that it is best implemented as separate
16 from the 911 system, but often becomes integrated with
17 those resources.
18 Q. When you were discussing the criticality of
19 response time for a cardiac arrest situation and you
20 were being asked questions in the context of a call for
21 ambulance transport, I think that we've got the person
22 who called 911 to get the ambulance transport in the
23 first place, correct?
24 A. Correct.
25 Q. We've got the first responder, correct?
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1 A. Correct.
2 Q. And we've got the ambulance, correct?
3 A. Correct.
4 Q. Of those three, which are you going to expect
5 to be first able to provide the continuous chest
6 compression that we want to see now for survive -- to
7 increase survivability?
8 A. So our hopes would be the very first person
9 that has contact with that patient, whether he or she
10 is a bystander. It's the very first person that's able
11 to do that.
12 Q. Because people who have heart attacks don't
13 usually pick up the phone and say, "I'm lying
14 unconscious on the ground"?
15 A. So as a clarification, heart attacks can.
16 Cardiac arrests cannot.
17 Q. Cardiac arrest, that's right. Thank you.
18 Cardiac arrest.
19 And so is that one of the reasons for AMR's
20 focus on doing continuous chest compression training?
21 A. Absolutely.
22 Q. And is it your experience that most competent
23 dispatch systems in this country are set up to talk
24 people who don't know continuous chest compression
25 through it?
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1 MR. MEYERSON: I'm going to object,
2 leading the witness.
3 ALJ SHEDDEN: All right. Again, with
4 the leading questions, alls I can do is determine what
5 weight to give.
6 So you can answer, Doctor.
7 THE WITNESS: So the -- there's still
8 some question about how many 911 centers provide
9 prearrival chest compression instructions, because
10 there are so many small dispatch centers. But the
11 majority -- it is the general sense in our profession
12 that the majority of 911 centers now provide prearrival
13 chest compression instructions.
14 BY MS. FICKBOHM:
15 Q. And with regard to the Hellsgate Fire
16 District, you don't have any reason to believe that
17 their EMTs and paramedics aren't carrying the necessary
18 equipment as a first responder to do chest
19 defibrillation or other CPR -- or other emergency
20 measures required immediately for a cardiac arrest?
21 A. I have no reason to believe that.
22 Q. Those are the only points of clarification I
23 had, Dr. Racht. Thank you so much.
24 ALJ SHEDDEN: Mr. Ray, anything?
25 MR. RAY: Nothing further. Thank you.
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1 ALJ SHEDDEN: Anything else,
2 Mr. Meyerson?
3 MR. MEYERSON: Yeah, just one question
4 on the paramedic/EMT.
5
6 RECROSS-EXAMINATION
7 BY MR. MEYERSON:
8 Q. Would you agree that in a prehospital
9 response, that a paramedic has a greater ability to
10 perform a more in-depth initial assessment of a patient
11 than an EMT?
12 A. I think in general that's correct.
13 Q. Okay.
14 MR. MEYERSON: That's all I have.
15 Thanks.
16 ALJ SHEDDEN: Anything else?
17 MS. FICKBOHM: No, thank you, Your
18 Honor.
19 ALJ SHEDDEN: No. All right. Thank
20 you, sir. We appreciate your time.
21 THE WITNESS: Thank you.
22 ALJ SHEDDEN: All right. Who will be
23 the next witness then?
24 MS. FICKBOHM: Doug Jones.
25 ALJ SHEDDEN: All right. Come on up.
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1 All right, let me get you sworn in.
2
3 DOUG JONES,
4 called as a witness on behalf of the Intervenor herein,
5 having been first duly sworn by the Administrative Law
6 Judge to speak the truth and nothing but the truth, was
7 examined and testified as follows:
8
9 ALJ SHEDDEN: All right. Go ahead and
10 state and spell your name for our record, please.
11 THE WITNESS: Douglas, middle initial
12 K., Jones. Last name is J-O-N-E-S.
13 ALJ SHEDDEN: All right. Whenever
14 you're ready, Ms. Fickbohm.
15 MS. FICKBOHM: Thank you, Your Honor.
16
17 DIRECT EXAMINATION
18 BY MS. FICKBOHM:
19 Q. Mr. Jones, what's your current position?
20 A. I'm the vice president of analytics and
21 operations research with AMR.
22 Q. And at what point in your career did you
23 start working in emergency medical systems, services
24 systems?
25 A. Back in probably 1988ish, ballpark. I was a
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1 volunteer on a small Fire Department in a suburban
2 community. I had finished my college degree. I got my
3 Bachelor's in electronics engineering and was working
4 in that field and kind of accidentally got into EMS as
5 a way of getting involved in the community and getting
6 to know people, and I accidentally discovered what I
7 was supposed to be doing.
8 Q. So was your family disappointed when you
9 didn't stick with electrical engineering?
10 A. Well, disappointed; they were concerned, I
11 think is a fair way of doing it. But I wasn't married
12 or had kids or anything, and was in a position to
13 follow my heart, and so I traded that off for a very
14 small hourly wage to do something I was more happy
15 doing.
16 Q. And where did that initial volunteer position
17 with a small Fire Department in 1988, where did that
18 take you?
19 A. Where did it take me?
20 Q. Professionally.
21 A. So I fell in love with the medical side.
22 Went to EMT school. Turned around and went to
23 paramedic school. About halfway through paramedic
24 school, got hired at a small private ambulance service
25 in Pueblo, Colorado, and started doing that full time.
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1 Through that, ended up leaving that organization for A1
2 Paramedics in Colorado Springs, Colorado, and as a
3 paramedic, who was eventually bought out by AMR, and
4 then basically worked my way through different levels
5 of management, most --
6 Q. Tell us what different things you've done in
7 your manager capacity with regard to ambulance
8 transportation.
9 A. Well, so field training officer, field
10 supervisor, operations manager, assistant director,
11 both with Pueblo and Colorado Springs operations,
12 primarily; and the operations manager piece was
13 probably the highest level at the operations level that
14 I attained, where I was running the ambulance service,
15 administering all aspects of the operations.
16 Q. And what other functions have you performed
17 within an ambulance transport entity?
18 A. So data, started working with data a lot,
19 largely out of an absence of anybody else being able to
20 do it. With my educational background, was kind of
21 drawn into it and decided to dive into it. Learned a
22 lot, studied under a couple different people
23 historically, kind of got my legs under me in that
24 category, and I started working on deployment planning,
25 demand analysis, geospatial analysis, and developed it
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1 so I could improve the systems that I was managing.
2 Q. And have there been any major technological
3 improvements or shifts at AMR as a result of your
4 efforts?
5 A. Yeah. So when I was brought into my first
6 corporate position as a national director, my job was
7 to be able to develop the tools, not only that I was
8 using, but were commonly available in the industry and
9 try to pick from the best of everything that's
10 available and put that into a system that was able to
11 do that, a lot of that functionality, for all of our
12 operations in the country. And that's what we did.
13 Over a period of a couple of years, designed
14 a system that we called OPAP, which is a --
15 Q. Another acronym.
16 A. Another acronym. I don't know why we do it
17 so much. But it stands for operations planning and
18 analytics platform, and it's a web-based application
19 that we take and we do all the heavy lifting,
20 basically, for the local operations with their data
21 that we basically take from all the different CAD
22 systems in the country.
23 Q. CAD being?
24 A. Computer-aided dispatching. Sorry.
25 And we build -- my team builds the business
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1 rules on the front end to make sure that we accurately
2 interpret all the specific things for each area, so we
3 can understand what is on time in this market, you
4 know, for this contract with these response times and
5 when's the clock start and when's it end and all the
6 little nuances within that system, so that we can then
7 use that data to help give them the information at
8 their fingertips anytime they want it without a heavy
9 lift, so that they can make good operational decisions
10 to help manage their business.
11 Q. And your background is set forth in some more
12 detail with some more specifics in LLA Exhibit 13a that
13 I have up in front of us?
14 A. Yes.
15 MS. FICKBOHM: Your Honor, I would move
16 for admission of 13a.
17 MR. MEYERSON: No objection.
18 ALJ SHEDDEN: 13a is admitted.
19 BY MS. FICKBOHM:
20 Q. As part of your background and training, are
21 you familiar with emergency medical services being
22 provided in small rural areas that might, in great
23 part, be serviced by a fire service or department?
24 A. Sure. Yes.
25 Q. And since you're working for AMR, is there
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1 any type of community, as far as size, rural, urban,
2 super-rural, frontier, that you don't work with?
3 A. No. I think we have examples of pretty much
4 every possible area and combination, probably, out
5 there.
6 Q. If you wanted to evaluate an ambulance
7 transport provider's ability to respond within a
8 particular area from a particular location, what the
9 timing of its responses might be expected to be, how
10 would you go about doing that?
11 A. So what we're talking about is kind of system
12 design, right, so -- and we do that all over the place
13 on a regular basis. We bid on a number of RFPs in
14 areas that we aren't even familiar with and have to
15 come through and do that same kind of effort.
16 But, basically, you start off with the -- the
17 two base components of any system design is, what is
18 the standards, response time standards, that we're
19 going to be held to, and what is the geography that
20 we're dealing with, what is our physical locations
21 going to be. And we build up that piece of it, that
22 is, that part, that footprint of what's necessary from
23 a resource standpoint to be able to respond and meet
24 our response time compliance as stated or desired, even
25 if it's not a contract.
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1 So we build that component and then we build
2 in what I call the capacity planning, which is the
3 demand analysis, looking at the patterning of all the
4 calls that have occurred through whatever period of
5 time we're evaluating.
6 And we focus an extreme amount of attention
7 on the task time that it takes to complete the call,
8 and we marry that information up together in order to
9 come up with that this is our deployment plan.
10 Q. And is efficiency within the system design,
11 so that it can be sustainable, one of the factors that
12 you build in, or do you take the utopian approach?
13 A. I generally take the utopian approach as a
14 starting point. You have to design a system in a way
15 that ensures your success from an on time compliance.
16 We use -- the response time compliance drives a lot --
17 a lot of what we do. It's a major component. I don't
18 want to minimize patient care or any of the other
19 things that we do, but in this category our on time
20 performance is what we're trying to balance everything
21 around.
22 Q. Is there a visual representation that you're
23 able to create regarding expected response time
24 abilities?
25 A. Yeah. So we have -- the geospatial aspect of
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1 when we're doing our evaluation, you have to take the
2 existing road network in the service area that we're
3 looking at, and every roadway has a speed that you can
4 generally travel on that roadway. We use that
5 information to create a drive time polygon, basically.
6 It's a -- it's -- if our -- let's say if our
7 response time standard was 10 minutes, we normally are
8 going to subtract some time off of that to account for
9 our out of chute, how long it takes us to get in the
10 ambulance and physically go. But we take that
11 parameter of -- say if it's a 10-minute standard and we
12 adjust it down for, let's say, a minute to allow for
13 proper out of chute time, that means we have a 9-minute
14 response time polygon. And they look all different,
15 but it's based on the actual roadways and the speeds
16 you can travel on those roadways.
17 And so then we lay that across the calls and
18 where the calls have occurred, to be able to measure
19 what percentage of those calls we can capture within
20 each polygon. And we add up more posting locations and
21 coverage until we adequately cover that within the
22 response time standards and the geography to be able to
23 come up with that plan.
24 Q. And are those -- does the diagram that ends
25 up getting generated as a result of that have fairly
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1 irregular boundaries?
2 A. Yeah, there are globs of misshapen spokes,
3 and they're not easy to describe except they are
4 realistic to what the conditions are based on the
5 geography and roadways that we're dealing with.
6 Q. If you didn't have the technological
7 resources or the -- to do what you just described --
8 well, let me back up and say drive time polygons, is
9 that state-of-the-art, or is there something that's
10 better than that to predict response parameters?
11 A. I think that's current state-of-the-art.
12 That's generally the approach that would be taken.
13 Q. If you didn't have the technological
14 resources in order to do a drive time polygon --
15 A. Yep.
16 Q. -- what other sort of rudimentary, less
17 perfect, less satisfactory measures could somebody
18 take?
19 A. So I'll just flash back into my own past on
20 some of the things that we used to do. Originally, we
21 came up with you just did the circles, right. Now, how
22 big is the circle is another trick, right. You can't
23 just create a circle from a common point and say
24 8 minutes is 8 miles or whatever and make a circle,
25 because your average response time speeds are generally
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1 very unimpressive.
2 You know, in the system I came from, just as
3 an example, our emergency response time average speed
4 was somewhere in the ballpark of around 35 miles an
5 hour.
6 Q. And what community was that?
7 A. That was in Pueblo, Colorado.
8 Q. And that was a mixed population center,
9 rural --
10 A. Yeah. We had a strong urban center. It's
11 about 100,000 people in the city itself; suburban,
12 we've got suburban communities around. We've got the
13 rural and even the super-rural stuff in that community
14 as well.
15 Q. So you would make your circles much smaller
16 than, for example, 60 miles per hour?
17 A. Yeah.
18 MR. MEYERSON: I would object to she's
19 either testifying in her questions or leading the
20 witness.
21 MS. FICKBOHM: I was just --
22 MR. MEYERSON: In this one leading the
23 witness.
24 MS. FICKBOHM: I was just circling back
25 to what he said, so I can ask the question.
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1 ALJ SHEDDEN: Well, I think that, you
2 know, there's, I guess, a question between clarifying
3 questions, one. But the objection is noted and
4 overruled.
5 BY MS. FICKBOHM:
6 Q. What was the next step in the progression of
7 what you used to do in the old days after circles?
8 A. So once we started to understand the
9 roadways, actually drive everything, then it was
10 becoming -- the tools that would be coming available in
11 that category that would allow us to use mapping
12 software to be able to look at the roadway speeds,
13 adjust the roadway speeds based on the area that we're
14 in, and start getting more accurate development of what
15 the coverage footprint would be from a geography and
16 response time standpoint.
17 Q. Are you aware of how CON 58 is currently, you
18 know, as -- let's just look at the last 30 days or so,
19 resourcing its service area?
20 A. From AMR's perspective, yes.
21 Q. And do you -- so have you analyzed resources,
22 response time compliance with its CON, call load,
23 et cetera?
24 A. My team has, and I've looked at it here as of
25 late, based on the reason we're all here; but, yes, my
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 947
1 team has actively worked in this area to be able to
2 evaluate.
3 Q. Do you think, with regard to personnel and
4 ambulances, CON 58 is underresourced?
5 A. No. Now, so I'm an efficiency geek, right.
6 I try to find what is that best balance of resources,
7 without overdoing it at the same time. My personal
8 opinion is, on our current staffing model in Payson,
9 from a data standpoint it is overstaffed some.
10 Now, you have to understand what my position
11 is and what my team's position is. We are not the
12 deciders of what goes on in a market. We are -- we
13 consider ourselves a strong customer service group, and
14 we make recommendations to the business leaders, so to
15 John and Glenn and other people within the company that
16 are truly managing the business units. We make our
17 recommendations based on the data.
18 And just like with just about anything, you
19 can't sit in a room in another state running numbers
20 and expect that you're going to come up with the
21 perfect plan for a local operation.
22 We deliver that information, present it, and
23 then there's an interaction that takes place, which is
24 the talking through any concerns, ideas on why this
25 should be different than what we've presented. And
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 948
1 then so they do the tweaking and adjusting, which I
2 think has happened in this example as well, and why the
3 staffing plan is exactly what it is.
4 It's a rural community. It's tough. You
5 can't run it like an urban area where you've got depth,
6 you know, major depth and easy backup very close,
7 right. So because of that, John's decision, and I
8 think it was appropriate, is, you know, to staff that
9 up a little bit stronger than would normally be
10 recommended based on data.
11 Q. If someone told you that looking back at the
12 last year's time, on average CON 58 had looked to
13 either another AMR-owned company or one of its local
14 EMS system partners X times per day to resource the
15 system, and let's assume X is 1 -- use that as the
16 number. -- would that indicate to you that the system
17 has not been appropriately resourced?
18 A. Not necessarily. It depends on what the
19 scenario, is a little bit, right. So sometimes using
20 mutual aid -- actually, I would say more than not the
21 use of mutual aid is a positive thing.
22 If you're going to staff to make sure that
23 you are covering a hundred percent of everything all
24 the time, there's a cost that goes with that, so -- and
25 most systems can't afford to do that, and that's why
COASH & COASH, INC. 602-258-1440 www.coashandcoash.com Phoenix, AZ
2017A-EMS-0006-DHS VOLUME 4 12/15/2016 949
1 mutual aid exists. That's why we share resources with
2 our neighboring operations, partnerships with Fire
3 Departments, whatever that is, because everybody
4 understands that sometimes things just don't work out
5 quite the way you plan, and you need to have good
6 backup plans and cooperating resources to be able to
7 help you out. And it works both ways, right. So that
8 everybody benefits and we cover some of those unusual
9 peaks when they do, those unusual occurrences.
10 Q. So is one thing that you would want to know
11 if somebody asked you that question, whether it was
12 really once a day or on one day there were like six
13 times because there was a multi-accident that piled up
14 and -- I mean is that information that would be
15 important to you?
16 A. Absolutely. So when we look at -- we would
17 categorize this from a data standpoint as a lost call,
18 a call that we wanted to run, but didn't. We handed it
19 off to somebody for some reason.
20 We would pattern all that by hour of day, by
21 day of week, you know, throughout what periods of the
22 year. We do the same kind of patterning with our --
23 anytime we have delayed calls. We look for the
24 patterns. We look for anything that is reasonable that
25 we should be covering that, or was it just an
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 950
1 exceptional situation, you know, like your example.
2 You might have six in one day because of an event, and
3 that's not something that necessarily changes how you
4 staff. That is an exceptional situation.
5 Q. You've been informed by the local operation
6 that the majority of calls in CON 58 come out of the
7 city of Payson, correct?
8 A. Correct.
9 Q. Okay. And you also understand that Payson is
10 where the only hospital in the area is, correct?
11 A. Correct.
12 Q. Okay. So knowing that -- and you also are
13 aware of the size of CON 58 and how much of it is
14 wilderness and rural land. In fact, I think I'll, in
15 connection with this question, pull up a map for you.
16 Here's the -- the pink is CON 58, and then
17 you've got within it the Tonto Basin Fire District.
18 You've got overlap with Rural/Metro (Maricopa). You've
19 got the Pine-Strawberry Department up here, et cetera.
20 But here's the map, and right there is Payson. Let me
21 show you another one here. Hold on.
22 The Hellsgate area is, generally speaking,
23 around here, and then here's the Greater Phoenix Area
24 down there. And I'm looking at, for purposes of the
25 record, LLA-21a.
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 951
1 Is the map familiar to you?
2 A. Yes.
3 Q. Okay. Knowing what you do about the source
4 of most of the calls and location of the hospital,
5 wilderness, urban -- or wilderness rural area, do you
6 believe that it is a bad model to staff a single
7 station in Payson, and by a "bad model" I mean a bad
8 model for an ambulance transport provider?
9 A. You mean just to have a single station?
10 Q. Correct.
11 A. So it's an interesting question, because the
12 environment in which that exists depends -- will have a
13 different potential outcome, right. So if I might, I'm
14 going to hit it from an urban angle first.
15 Q. Okay.
16 A. And then I'll answer that part of the
17 question.
18 So in an urban system, we do a fair amount of
19 what we call double-posting, right, so we actually have
20 two ambulances sitting in the same location ready to
21 respond on calls. The reason we do that is because
22 when you identify what your base geography footprint is
23 that you need, so I know if I have, whatever, these six
24 posts locations covered all the time, I know that I
25 will be successful on my on time performance standards,
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 952
1 right.
2 I can put ambulances further out and try to
3 catch the onesie, twosies, outskirts types of calls,
4 right, but that's -- you know, why would I move out to
5 try to capture those when I know when there's -- you
6 know, 98 percent of the time the volume is coming out
7 of this area.
8 Q. And "this area" meaning the --
9 A. In that core volume area where the calls are
10 happening, right.
11 So in Payson, this is a rural example of
12 this. And we see this every once in a while in other
13 areas as well. If that is where the calls are
14 happening, then it doesn't make a whole lot of sense to
15 start spreading these resources out. Because what
16 happens is, is you get the call clusters. They come in
17 pairs. You get one call comes in and two minutes later
18 another call comes in, also.
19 So the more spread out that you are,
20 depending on what the volume that you're trying to
21 cover is and where that's occurring, it can
22 actually take a longer response time to get back into
23 the system, and you can cause more harm to the more
24 calls by spreading out to cover small amounts of
25 volume.
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 953
1 So it's very situation-dependent, but I don't
2 have an issue with it in Payson. Once we get to three
3 ambulances in one location, I start to scratch my head,
4 and I've brought that up to John. But, you know, until
5 we get some of these issues settled out, I don't -- you
6 know, we want to make sure that we're heading in the
7 right direction before we make more investments in
8 doing things like that.
9 Q. By "these issues settled out," you mean the
10 issue of whether or not Life Line Ambulance will be
11 able to continue being --
12 A. Yeah, if our business is potentially at risk,
13 the timing is not great right now to try to make moves
14 like that.
15 Q. When you were looking at Life Line's
16 performance in this area, did you want to look at out
17 of chute time?
18 A. I always want to look at out of chute time.
19 Q. Okay. And were you interested in what
20 Hellsgate's out of chute time is?
21 A. Yeah. I'm interested in everybody's out of
22 chute times when I'm analyzing the area. It's a major
23 factor. I think it's undervalued by a lot of people.
24 But, so we're talking about from the time
25 that that unit gets dispatched until the time that
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 954
1 they're in their unit and responding, right. So it's a
2 category of our overall response time that oftentimes
3 is missed when you're looking at the assessment.
4 Now, we're very aware of out of chute time.
5 So to me, it is a category of wasted seconds, right.
6 It's -- there's -- some of it is out of necessity.
7 This is why we generally, like in an urban area, don't
8 have 24-hour units, right. We're in quarters and the
9 crews are sitting in recliners watching TVs or
10 something.
11 That extra time it takes from the time the
12 call comes in to get up, get your shoes on, put your
13 coat on, whatever that is, walk out to the vehicle,
14 physically leave the station, that is time that's
15 taking away from my response time window, right.
16 So it makes a big impact. If you're sitting
17 in your ambulance ready to go, that's the most optimal
18 situation. And if you're actually moving a little bit,
19 that helps even more. If I could just trim 5 seconds
20 off of out of chute times, that's a big deal, right.
21 That's that much more time I have to get on scene.
22 And if you look at this from the customers'
23 perspective, who is our patients, and we have lots of
24 customers, but from our patients' perspective, they
25 could care less of what it is that's taking us so long
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1 to get there, right. We want to shave that off as much
2 as we can. They just want to know from the time they
3 call to the time somebody shows up.
4 Q. So were you able to find a resource to see
5 Hellsgate Fire District's average out of chute time?
6 A. The one thing I did see is just reviewing
7 from their website and pulled up the most recent fiscal
8 year report. I think it was '14-'15 was the date on
9 the report. But the time frame that I understood to be
10 their, what I call out of chute time, is their turnout
11 time, and for that fiscal year period, their average
12 turnout time was a minute and 40 seconds.
13 Q. And what about CON 58?
14 A. Well, that was the Hellsgate time frame. So
15 I don't know if that covers the whole CON. My
16 assumption is that is just for that Fire Department
17 specifically.
18 Q. Right. And did you look at the out of chute
19 time for CON 58?
20 A. Oh, yes. From the AMR perspective?
21 Q. Yes.
22 A. Yeah. We look at that stuff all the time.
23 They've run, over the period of the last year, right in
24 that 40-second range. And the numbers I pulled up this
25 morning, just to double check and see where we were at,
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 956
1 and a four-week trending on that was running at a
2 43-second average.
3 Can I say one more thing about out of chute
4 times?
5 Q. Since you obviously like it so much, yeah.
6 A. Well, and I'm -- yeah, I do, I love this
7 stuff.
8 Averages are -- averages are averages. They
9 really don't tell the whole story, right. So if we've
10 got an average out of chute time of 43 seconds, I know
11 that in the daytime when they're moving, the chances of
12 having a much quicker out of chute time average during
13 the day is probably very likely; and at night, if
14 they're down and napping or whatever they're doing, I
15 know that it's going to be more than that.
16 So a simple way of looking at that is, if
17 I've got a 40-second average, at night I bet you
18 that's, you know, as much as twice that sometimes,
19 right; and in the day maybe it's half that. And
20 there's a balancing and a weighting on that that goes
21 on.
22 So on the same respect from a minute and 40
23 on the turnout time, you can make the same assumptions.
24 And that's eating up a lot of important minutes.
25 Q. So I want to ask you another question and
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1 just establish your awareness of a couple of facts
2 first.
3 You're aware that the historic call volume in
4 this area is significantly under 4,000 calls a year,
5 correct?
6 A. Correct.
7 Q. And you're also aware of the fact that the
8 majority of the area is wilderness and rural, twisty
9 roads; as Hellsgate's GIS person put it, you can't get
10 there from here?
11 Yes?
12 A. Yes.
13 Q. So based upon your training and experience,
14 do you believe that two providers could cover
15 essentially an identical -- the identical service area
16 with that volume of calls and both be sustainable?
17 A. The last part of what you said is the
18 problem, right, sustainable. The financial viability
19 of our rural systems is tough. That's why the
20 reimbursement in rural areas is higher than it is in
21 urban areas. It is hard to be able to sustain things
22 from a cost and efficiency basis.
23 Ambulance service, in my personal opinion, I
24 don't have a problem with competition, right; but I
25 have a problem with competition directly in the market,
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 958
1 especially in the 911 category, because it makes it
2 very difficult. You're duplicating resources to be
3 able to try to take care of the same thing, and it
4 costs the system a lot more money to do that. And the
5 likelihood of individual providers being able to
6 survive in that scenario is much less.
7 MS. FICKBOHM: Thank you, Mr. Jones. I
8 don't have any other questions.
9 ALJ SHEDDEN: Mr. Ray, any questions?
10 MR. RAY: Yeah, just a few.
11
12 CROSS-EXAMINATION
13 BY MR. RAY:
14 Q. Good morning Mr. Jones.
15 A. Good morning.
16 Q. I am the Bureau of EMS's attorney.
17 So I want to get into how you arrived -- or
18 how you reached the conclusion that the current CON 58
19 staffing is, from a data standpoint, overstaffed. So
20 that's where I want to go.
21 A. Okay.
22 Q. Let's start with a definition. When you are
23 looking at staffing, what does that mean? Does that
24 mean equipment, personnel, both, something in addition?
25 What are we talking about?
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1 A. So, generally, the combination of equipment
2 and personnel, as well as facilities, if appropriate.
3 So when I talk about staffing, I'm generally talking in
4 terms of unit hours.
5 Q. Okay.
6 A. Right? So a unit hour would be comprised of
7 a crew, qualified, certified to the levels that they
8 need to be, in a transport-capable vehicle that meets,
9 you know, whatever the requirements are there, with all
10 the equipment they need to be able to meet the
11 standards there. If they're in service for one hour,
12 that would be one unit hour. So there's two people,
13 maybe, involved in that, but it creates one unit hour.
14 So usually we evaluate that as a resource
15 that is needed to take care of a call, and however long
16 it takes them to take care of that call would then
17 comprise their task time.
18 So that task time piece plays a major role,
19 right. So, for instance, I'm aware that the hospital
20 is right there in Payson. So in a lot of emergency
21 calls, our task time is much shorter than it would be
22 if we were picking up an interfacility patient out of
23 that hospital and heading down into Phoenix, and the
24 time -- because you can't just count the time that they
25 get to Phoenix and drop off their patient, because
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1 until they're back in their primary service area,
2 they're really not available. Even though they aren't
3 tied up directly on the call, they're on the
4 aftereffects of the call.
5 Q. So it sounds like you use unit hour
6 utilization as your -- as one of the formulas driving
7 your analysis for staffing?
8 A. It actually is a -- it's a result of the
9 analysis. Transport utilization or UHU, unit hour
10 utilization, is not a driver of anything that we do,
11 from my department's perspective.
12 As a matter of fact, I have refused to
13 include that metric in any of our design pieces within
14 our OPAP platform. In the demand analysis section,
15 where you can run these demands, which I'll go into a
16 little bit more to answer your question, it's not
17 there.
18 Transport UHU is what I would consider to
19 be a financial indicator, right. So we generate
20 revenue off of a transport. Therefore, however many
21 transports we have in a certain period of time, a
22 number of unit hours would -- that's how you would
23 derive your transport UHU. That doesn't mean that your
24 system's covered. That's, again, a financial
25 indicator.
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1 I'm not minimizing the importance of it, but
2 not from my team's approach, right, from a system
3 design approach. Whether or not it's going to make
4 money, that's somebody else's issue. We're going to do
5 it on the design piece to make sure that we've got the
6 right amount of resources there to be able to service
7 the customer, because it's not just a transport. It's
8 also, like I just mentioned, what we call that dead
9 leg. When you're out of your service area, but you're
10 cleared off your call, we actually capture that time
11 element until they get back into their primary service
12 area.
13 You have dry runs or refusals, where the --
14 part of providing good care to your community is you
15 need to respond on those calls. They don't all, you
16 know, eventually land as a transport.
17 Q. So if you don't use unit hour utilization to
18 arrive at the decision as to whether a particular
19 location is understaffed, overstaffed or staffed just
20 right, what do you use?
21 A. It's task time, task time and the combination
22 of the call history and how those calls combine against
23 the number of resources that are potentially available
24 to service those calls.
25 Q. Okay.
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 962
1 A. So it is a --
2 Q. So task time would be different in a pure 911
3 system than a mixed 911 and interfacility system?
4 A. Task time is different in every system. You
5 know, it's the old adage of if you've seen one
6 ambulance service, you've seen one ambulance service.
7 Because all of them are different, and so
8 it's very hard to come across and say this is -- this
9 is the right answer for all of our services. Now, in
10 general, we try to be efficient, right. But we have to
11 design the system around being able to meet the
12 requirements or the standards set forth that we need to
13 meet, generally in terms of response time performance
14 is one of the primary drivers of that.
15 Q. Okay. So if you were making a decision based
16 on your data only, what would be the appropriate
17 staffing for CON 58, in your opinion?
18 A. So it's based on the combination of the
19 geographical footprint, the roadway speeds, the calls
20 and the patterning of the calls and where they're
21 falling, combined with that capacity of, well, these
22 are all the calls that we ran during this period that
23 we're going to evaluate. And when we marry that all up
24 together, I would have to reference my materials to be
25 able to give you the exact number, but it's ballpark
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 963
1 around probably 60 unit hours less than what's being
2 done currently in that market.
3 Q. Okay.
4 A. And that's per week. Sorry.
5 Q. Okay. So let's assume 10 calls a week -- and
6 this is a hypothetical number. -- are being transferred
7 to other providers to do those calls.
8 How do those 10 calls a week factor into
9 your --
10 A. Great question.
11 Q. -- analysis?
12 A. Yeah, great question.
13 So this is that lost call category. We look
14 at those as if they were calls that we actually ran
15 when we are doing our demand analysis work. So we have
16 visibility to the fact that we had a call that we
17 wanted to run, but didn't. We passed it off on a
18 mutual aid situation.
19 We take that call, and although we don't have
20 visibility to all the times after we handed that off,
21 we'll take the average task time in that market, we add
22 it to the start time when we know the start of the call
23 occurred, and when we do our demand analysis, we
24 evaluate that call and any lost call as part of the
25 overall calls that we ran, pretending, right, so that
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1 we design the system off of that.
2 We also design it, from an interfacility
3 transport standpoint, that if we were late on an
4 interfacility call, we actually shift the time in the
5 demand so that we build the demand off of being on time
6 instead of being late, right.
7 Q. Okay.
8 A. So we do a number of adjustments to the data
9 to try to make sure that we're recognizing everything
10 we possibly can that would realistically contribute to
11 the way that system should be designed --
12 Q. Okay.
13 A. -- and covered.
14 Q. Okay. So I think the takeaway from your
15 answer was that even if you roll calls to other
16 providers, you utilize that data in determining whether
17 your current staffing model is appropriate or not; is
18 that fair?
19 A. That is fair, yes. It's kind of like that
20 dead leg portion, right.
21 Q. Say -- I'm sorry?
22 A. That dead leg portion. If we're measuring an
23 IFT call that came out of Payson and went into the City
24 somewhere, that time portion of going back up into
25 Payson, that's a significant piece of time.
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 965
1 Q. Yes.
2 A. If I build a system off of not recognizing
3 that, then I'm going to underestimate what resources it
4 would take to get it.
5 So we spend a lot of time and effort trying
6 to make sure that we're gathering all the information
7 that we possibly can, to give the most accurate
8 recommendations that we can.
9 And they're still subjective, because the
10 business leader can make adjustments to that above and
11 beyond what we've recommended. We've given them this
12 is what the perfect plan would be, and they usually
13 will, you know, push that up just a little bit so that
14 they are covering things from their perspective as
15 well, you know.
16 Q. Sure.
17 A. It's on top of the data.
18 Q. So focusing on what the perfect plan for
19 CON 58 currently is, does that perfect plan build in an
20 assumed number of transfer calls?
21 A. No, because, again, I don't care if it's a
22 transport or what kind of call it is. It's segments of
23 task time, and we actually break it down into 5-minute
24 intervals. So most demand analysis stuff is done on an
25 hourly basis. The problem with taking that approach
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2017A-EMS-0006-DHS VOLUME 4 12/15/2016 966
1 is, is that you have to make the underlying assumption
2 that your task time is about 60 minutes, on average.
3 That's a huge assumption to make, right. So I might
4 have a call that we get canceled en route. It only
5 took five minutes task time. That was it. I wouldn't
6 want to show that as it took an hour. Or the other
7 side of it is, I send somebody to the hospital in town
8 and coming back. Well, that's a lot more than an hour.
9 And the patterning of when the timing of all
10 these things happened contributes greatly to that
11 system design plan. So the 5-minute increments
12 allows us to measure how many units are active every
13 5-minute interval, to make sure that we can see exactly
14 what is needed and how we can be successful in this
15 system.
16 Q. So how often do you run these analyses?
17 So --
18 A. All the time. It's a --
19 Q. So how often would you pick up the phone and
20 call Mr. Valentine or --
21 A. Monthly.
22 Q. Okay.
23 A. Monthly for my team's interaction with the
24 operation. But the great thing about OPAP is, is that
25 we put it in a web platform where, literally, if John
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1 wants to run or Glenn, anybody wants to run, from our
2 organization, the demand analysis for Payson, they
3 literally have to select Payson from the pull-down. We
4 have all the settings by default already set up for
5 them, and they hit run. There's not any kind of formal
6 knowledge on the front end on how to do it.
7 That's part of the beauty of that
8 application, is we do all that for them all the time by
9 helping them manage that data to make sure the data is
10 in good shape so that they can push a button anytime
11 they want to. And we recommend it actually is looked
12 at daily. Because not that the demand changes daily,
13 but you can also see what your active call volume was
14 on the previous day.
15 We spend tons of money and effort and time on
16 hiring the right people, trying to meet Dr. Racht's
17 standards on clinical excellence, ambulances,
18 equipment, all these things, so that we can try to be
19 in the right place at the right time, right.
20 If we don't evaluate how we are actually
21 doing on that plan every day, then it's -- I consider
22 that to be a disservice to all the effort and time
23 we've spent on all the other pieces, right. You have
24 to evaluate we had a plan, we staffed it, we had the
25 right equipment and everything; how did it work. And
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1 you can evaluate that very easily on a daily basis with
2 a push of the button.
3 And that's in all of our operations that we
4 have their CAD data flowing into, into OPAP, and we
5 have for Payson here for the last -- for this last
6 year, ballpark, since we merged.
7 Q. Okay. So at your shop, is it fair to say you
8 monthly communicate reports and data on this, the
9 appropriate staffing level, to your managers, whether
10 it's in Payson or someplace in Colorado, and --
11 A. Right.
12 Q. But that those separate managers also have
13 the ability to pull that information whenever they need
14 it?
15 A. Yeah.
16 So our cadence is monthly meetings and
17 interactions. Sometimes that switches around. I would
18 have to investigate to find out for sure it happened
19 every single month with -- you know, with CON 58; but
20 that's our cadence, right.
21 And the purpose of those is not to show them
22 everything. It's just to kind of give them our
23 experienced eyes on what we're seeing, right. So we
24 shouldn't be telling them anything they don't already
25 know, but we are advisors.
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1 So my OPAP manager for the south region is
2 the one that would be having that conversation with the
3 operations folks and just pointing out anything that he
4 sees as like, "You guys notice a little trending up on
5 your drop times at the hospital, right?"
6 "It's only 3 minutes. What are you talking
7 about?"
8 "Well, 3 minutes, that's kind of a big deal.
9 What's going on? What's the driver of that?"
10 Those are the types of conversations that we
11 have. So we challenge, is kind of the whole point, is
12 to challenge them to make sure that they're doing
13 everything that they're supposed to; and we counsel
14 them the best we can on things they can do to help make
15 better decisions.
16 Q. All right. And when was the last time you
17 did your review for purposes of determining their, from
18 a data perspective, overstaff?
19 A. A couple nights ago I ran it. Ran it myself
20 and just evaluated it just to take a quick look at how
21 the demand was laying out across everything.
22 MR. RAY: All righty. Thank you --
23 THE WITNESS: Yep.
24 MR. RAY: -- Mr. Jones.
25 ALJ SHEDDEN: All right. Let me just
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1 verify, Mr. Meyerson. You have questions, I assume?
2 MR. MEYERSON: I do.
3 ALJ SHEDDEN: And does it make sense to
4 take our lunch break first, from your perspective?
5 MR. MEYERSON: Yeah, I think it would be
6 a good idea.
7 ALJ SHEDDEN: All right. We're right
8 about 20 to 12:00, so why don't we meet up in an hour
9 and a half at 1:10.
10 (A lunch recess was taken from
11 11:39 a.m. to 1:11 p.m.)
12 ALJ SHEDDEN: All right. We're back on
13 the record. The recording is going again. Mr. Jones
14 is back in the witness chair. I'll just let you know
15 again, like yesterday, although we had a little hitch
16 in our plans yesterday, we'll go ahead and take two
17 shorter breaks this afternoon, rather than one longer
18 one. So we'll go about an hour and 10 minutes, take a
19 break of about 10 minutes, and then do it again.
20 But with that, whenever you're ready.
21 MR. MEYERSON: Okay.
22
23 CROSS-EXAMINATION
24 BY MR. MEYERSON:
25 Q. You provided some testimony earlier about the
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1 mapping and -- that Hellsgate had done in preparation
2 in its application and submitted with its exhibits.
3 Did you do a detailed analysis of the response time
4 tolerances that were proposed by Hellsgate in its
5 application?
6 A. I didn't have anything to do it on from
7 Hellsgate's perspective, but I did from AMR's. I did a
8 couple quick, not in depth, just for illustration of
9 the differences. And we did some original work on it,
10 you know, six months ago or whenever it was that we got
11 started.
12 Q. So you're not testifying today that Hellsgate
13 can't make the response times that it proposed in its
14 ARCR, right?
15 A. So we're talking about the response circles?
16 Q. No, I'm saying the response times in its
17 ARCR.
18 A. Oh, no, no, no, no. I'm not implying that at
19 all. Correct.
20 Q. You testified also that you believe that
21 CON 58 is overstaffed?
22 A. Okay. Yes.
23 Q. Yeah?
24 A. Yes.
25 Q. Can you provide us an analysis to show us
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1 that?
2 A. I certainly could, yes. So -- and we've got
3 the tools to do that.
4 Q. Okay.
5 A. That's what my Department does --
6 Q. Okay. I --
7 A. -- is evaluate that, right. So -- and,
8 again, we propose from just a data perspective what our
9 recommendations would be, and I base my opinion on what
10 that is, and then it's tailored by the operation to
11 suit -- you know, to suit the needs of the business as
12 appropriate. But yeah.
13 Q. Did you provide us the analysis to show us
14 that CON 58 is actually overstaffed?
15 A. I did not.
16 Q. Can you explain to us why the Maricopa-based
17 ambulance is being used in Payson, on average, one and
18 a half times per day if, in fact, CON 58 is
19 overstaffed?
20 MS. FICKBOHM: I'm going to just make an
21 objection. And the objection is, I believe that
22 assumes facts not it evidence, because counsel is
23 including a body of data that wasn't established
24 actually resulted in CON 58 not responding to the
25 scene. And I'm referencing the Payson and Strawberry
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1 data.
2 ALJ SHEDDEN: All right. And do you
3 want to respond to the objection, Mr. Meyerson?
4 MR. MEYERSON: Yeah. I mean, her
5 objection is irrelevant. The 368 Maricopa-based
6 ambulances is in evidence, and it's actual transports
7 done by those ambulances. It's through 244 days of
8 2016, and if you divide 368 by 244, it's a fraction
9 over one and a half. So I'm not quite sure what the
10 objection is.
11 MS. FICKBOHM: So I --
12 ALJ SHEDDEN: Yeah, go ahead.
13 MS. FICKBOHM: I guess I understood that
14 you were talk -- so you're just talking about the
15 actual Maricopa entity provider reported information to
16 DHS?
17 MR. MEYERSON: The actual Maricopa
18 County ambulance transports done in CON 58.
19 MS. FICKBOHM: Okay.
20 MR. MEYERSON: Actual numbers.
21 MS. FICKBOHM: And I hadn't averaged
22 that out. I'll withdraw my objection. It is what it
23 is.
24 ALJ SHEDDEN: All right. You can answer
25 the question.
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1 THE WITNESS: So I can speak in general
2 on some of this, right. So if -- my perception is, is
3 that we have had Maricopa ambulances going up and
4 taking some of the interfacility transport calls to try
5 to make sure that we have availability in the 911
6 system and not drain that system.
7 So when you're talking about whether or
8 not the staffing currently today is the same as when
9 those situations occurred, that's the part that I can't
10 specifically speak to and say, yes, staffing was too
11 much back then and then have an explanation for you,
12 because I don't know that that's the case.
13 BY MR. MEYERSON:
14 Q. Okay. The -- I guess what is the peak load
15 for CON 58?
16 A. I don't have that information in front of me.
17 I don't know.
18 Q. Do you know what hour of the day is the
19 highest demand of CON 58?
20 A. For medical calls, I assume we're talking?
21 Q. For calls on -- for calls for services on
22 CON 58, yes.
23 A. But, again, are we talking about
24 medical-related calls, of which AMR would be responding
25 to?
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1 Because I can't necessarily speak to calls
2 that we don't get. But in general, that trending, we
3 see a little higher trending on Tuesday through Friday.
4 Q. And that's specific for CON 58?
5 A. That is specific for CON 58.
6 I know looking at the annual report stuff
7 from the Fire District, it's Saturday tended to peak
8 more; but I have to assume that there's more calls that
9 we wouldn't respond to helping to affect some of these
10 numbers.
11 Q. And what is CON 58's average time on task, I
12 think is the term that you used?
13 A. It is, and I'll have to be a little bit
14 ballparky here. I apologize. But on your 911 calls
15 within the system itself, ballpark, around 45 minutes.
16 And it's much higher than that when we're doing our IFT
17 calls going into town. I want to say it's up in the
18 120-minute range, but I probably shouldn't even guess,
19 because I would have to verify that information for
20 you.
21 Q. And do you know how many times CON 58 has run
22 out of units in 2016 or doesn't have a CON 58 unit
23 available?
24 A. I don't, specifically, no.
25 Q. You've reviewed the call load in preparation
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1 for this hearing. You said in the last 30 days you've
2 looked at it a few times. But we don't have any detail
3 on the reasons for any of the 368 interfacility
4 transports; is that correct?
5 A. We don't -- you're saying you don't
6 understand why we've got 368 interfacility transports
7 done by Maricopa, is that your point?
8 Q. My question is, we don't have any breakdown
9 of any of that information. There's been testimony
10 earlier or suggestion earlier that those are
11 prescheduled calls or a Maricopa County ambulance is
12 already up in the Payson area and, therefore, that's
13 why it did that call.
14 But we really don't know any of that, because
15 there's no information being provided by Life Line in
16 that regard, correct?
17 MS. FICKBOHM: I'm going to object to
18 the form of the question as misstating what's happened
19 thus far.
20 ALJ SHEDDEN: All right. How so?
21 MS. FICKBOHM: What was established
22 during the applicant's case-in-chief was that some of
23 them would involve situations like counsel's talking
24 about, and we didn't really know how many. It wasn't
25 that all of them were that. That -- nobody elicited
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1 that testimony.
2 ALJ SHEDDEN: All right. Mr. Meyerson,
3 do you want to respond?
4 MR. MEYERSON: I think the testimony
5 that was provided in our case-in-chief was more a
6 could, to create some level of doubt regarding -- you
7 know, suggesting that these interfacility transports
8 were based on, you know, legitimate reasons, not lack
9 of resources.
10 And so I'm just asking the witness that
11 would seem to have access to that information the
12 question about that information.
13 ALJ SHEDDEN: Well, I guess the thing
14 that jumped out about me was, I don't know that Life
15 Line had to present any evidence on this. So that was
16 the -- so when you said Life Line didn't present any
17 evidence on it, you know, I'm not sure they were
18 obligated to.
19 I'll overrule the objection, and you can
20 answer.
21 THE WITNESS: So it's being portrayed as
22 that's a negative thing. I don't have all the details
23 on each of those calls, but the way that I look at
24 things, that's not a negative thing. That's tapping
25 into the resources that we have in order to best serve
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1 a community.
2 That's one of the good things about
3 servicing a rural community when you also support the
4 larger urban centers, the ability to share resources to
5 help augment things, for whatever reason. Whether it
6 was, you know, practically, this was absolutely needed
7 or it was scheduled or they were there anyway, that's
8 almost inconsequential. It's taking advantage of the
9 opportunity that we have to be able to do something
10 like that. I don't think -- my opinion is, that's not
11 a bad thing.
12 BY MR. MEYERSON:
13 Q. So it was described earlier as the Maricopa
14 County ambulances coming up as a form of mutual aid; is
15 that correct?
16 A. You could call it that. I don't call it
17 mutual aid when it's amongst our own operations,
18 but fair enough. That's a close enough example, I
19 guess.
20 Q. And by "our own operations," you're talking
21 about AMR generally?
22 A. Correct. We have sister neighboring
23 operations, and it is an advantage when they're close
24 enough to be able to help, to be able to run those
25 calls in, whether they're there or these guys are short
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1 and you're able to kind of shuffle some of those
2 resources and tap into the power of having that
3 networking piece together.
4 Q. Do you know where Pine-Strawberry is?
5 A. I'm familiar with the name. I know it's in
6 the general vicinity, and it's another Fire District
7 right in the area; but not specifically. I've
8 never and don't purport to know all the specifics about
9 Payson enough to be able to tell you exactly where
10 that's at.
11 Q. Is it your understanding, though, that
12 Pine-Strawberry is closer to the Payson area than
13 Maricopa County?
14 A. Yes, I believe that to be true.
15 Q. And earlier we heard testimony about a verbal
16 mutual aid agreement between Pine-Strawberry and CON 58
17 and that they would respond in if CON 58 were short on
18 ambulances.
19 Does it make sense to you that that auto-aid
20 doesn't apply to any interfacility transports that
21 might go out of the area?
22 A. Sure. So timing of the need is a big factor
23 there, right. So if we're talking a 911 call that's
24 holding, then, yeah, that would make sense; go for the
25 closest resource to bring them in to help you.
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1 In an interfacility transport scenario, the
2 timing is generally such that you can schedule and plan
3 your resources around the demand as needed. And I
4 would -- I certainly wouldn't want to have to put
5 another District out of -- out of sorts because of
6 something that wasn't, from a timing standpoint, an
7 urgent need.
8 So timing would be the biggest definer for me
9 on whether or not it would be more appropriate to do
10 mutual aid with them versus our own resources coming up
11 from a different location.
12 Q. But you are pulling a resource from another
13 area, just not Pine-Strawberry; but you are having to
14 pull a resource from Maricopa County to come do that
15 anyway. So we are pulling -- whether it's an AMR
16 company or a non-AMR company, it seems to me that
17 keeping it within the family is maybe more important
18 than getting it -- getting a closer mutual aid partner
19 to the area to provide the transport; is that --
20 MS. FICKBOHM: Your Honor, I'm going
21 to object to the form of the question because,
22 basically, he's not giving the witness all the facts,
23 which include Pine-Strawberry not being certificated
24 by the State of Arizona to do interfacility
25 transports.
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1 ALJ SHEDDEN: All right. And let me
2 ask, Mr. Meyerson, you would agree that the Chief, I
3 think it was Chief Morris from --
4 MR. MEYERSON: Yes.
5 ALJ SHEDDEN: -- Pine, said that they
6 weren't certificated for IFTs?
7 MR. MEYERSON: Yeah. Yeah, that's
8 correct, except that it's my understanding that if a
9 CON holder is unable, under their own certificate, to
10 provide an interfacility transport, that if they were
11 asked by a CON that does have that, that they would
12 have the ability to do that interfacility transport, I
13 guess if they're asked. They're not allowed to do it
14 on their own, but they could fulfill that duty if
15 necessary.
16 ALJ SHEDDEN: All right. With that
17 additional information, you can phrase your question to
18 the witness however you would like.
19 BY MR. MEYERSON:
20 Q. Okay. So Pine-Strawberry, which is much --
21 or I won't say much; which is closer than Maricopa
22 County -- and, you know, I think I'll pull up an
23 exhibit to help us out here. So I'm going to go to
24 Hellsgate Exhibit 16, and this is the total number
25 of -- and I'll rotate this. This is the total number
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1 of mutual aid calls that it received in 2016 through
2 November. It's already been admitted as evidence, but
3 we'll go through November.
4 Can you read for us how many calls total that
5 says?
6 A. It looks like there's 8 total.
7 Q. No, it's actually written in there. I
8 apologize. It's the handwritten number at the top of
9 that page. The 26?
10 A. So 26 calls, but I don't see 26 calls here.
11 Q. Yeah, it's a multipage document.
12 A. Oh, I see what you're saying. Okay.
13 Q. Yeah. So it provided 26 calls. It's closer.
14 And Maricopa County ambulances provided 368 calls. And
15 my question was, why wasn't a closer partner that could
16 provide those interfacility transports used; what,
17 8 percent of the amount that the Maricopa County
18 ambulances were used?
19 MS. FICKBOHM: And I'm going to object
20 again. Payson doesn't even have a CON. This is -- is
21 this -- no, this is Payson. This is -- is this
22 Pine-Strawberry or is this Payson?
23 MR. MEYERSON: This is Pine-Strawberry.
24 MS. FICKBOHM: Oh, I'm sorry. I
25 misunderstood.
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1 And I guess my only objection is that I
2 thought we established through Captain -- or Chief
3 Morris that he doesn't know that all of these resulted
4 in a transport being done, and, in fact, some of these
5 could have been canceled within minutes of the call
6 coming in and CON 58 could have performed the
7 transport. Didn't he say that?
8 MR. MEYERSON: Yeah, but that would make
9 my point even worse.
10 ALJ SHEDDEN: Well, I'm going to tell
11 you, I don't -- here's the problem I have with this
12 line of questioning, just to be clear: It would seem
13 to me to be silly for the -- Life Line to call
14 Pine-Strawberry if they needed an interfacility
15 transport to go from Payson to Maricopa County. I
16 don't understand why that would make any sense. I
17 heard the Chief say they've got two ambulances. So
18 under the scenario that's being laid out here, you'd be
19 calling Pine-Strawberry to take an ambulance out of
20 service for a couple of hours at least.
21 So my assumption would be that these
22 questions would have been asked on some sort of
23 follow-up of this witness.
24 But with that, one, we don't know where
25 the transports went, to my knowledge. The exhibits
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1 don't show that. But it doesn't seem to me to make a
2 lot of sense to call on Pine-Strawberry to do an
3 interfacility transport to Phoenix.
4 Let me just ask the witness a question.
5 Do you know how many ambulances the AMR folks have in
6 the Phoenix Metro area?
7 THE WITNESS: Tons.
8 ALJ SHEDDEN: So a hundred?
9 THE WITNESS: Well, we're talking
10 physical ambulances or what we're peaking at? It's
11 not -- I don't think it's as high as a hundred, but I'm
12 ballpark guessing. It's up in the, probably, 60, 70
13 range peaking.
14 ALJ SHEDDEN: And you're aware that
15 there are other CON holders in the Phoenix Metro area
16 now, correct?
17 THE WITNESS: Yes. Yes.
18 ALJ SHEDDEN: So -- but I'll let you ask
19 your questions, but, you know, as we embarked down this
20 road, that's what hit me. Why would you call on a
21 provider with only two ambulances to take them out of
22 service, go a hundred miles from Pine-Strawberry, I
23 guess probably a little further than Payson to get to
24 Phoenix. But that's what I'm having trouble
25 understanding.
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1 But let me go back to Ms. Fickbohm. So
2 understanding then that certainly Chief Morris didn't
3 know whether all of these calls resulted in transports,
4 that's your only objection at this point?
5 MS. FICKBOHM: That's my only concern,
6 because he seemed to be implying to the contrary to the
7 witness.
8 ALJ SHEDDEN: All right. Go ahead and
9 ask whatever question you would like, Mr. Meyerson.
10 BY MR. MEYERSON:
11 Q. Okay. So let me clarify a little bit; is
12 that the mutual aid requested by CON 58 resulted, we'll
13 concede in this context, less than 26 calls to
14 Pine-Strawberry. The mutual aid requested from its own
15 family of companies from Maricopa County resulted in
16 368 interfacility transports. We don't even know if
17 there are non-CON 58 ambulances from the family that
18 provided emergency/911 transports in the area.
19 My question is that disparate treatment of
20 these two. I understand the judge's point, and I want
21 to be careful not to testify to you. So I'll let you
22 answer that. I assume your answer is the same or
23 similar to his?
24 A. Yeah, so the -- again, the how close they are
25 is not necessarily a determining factor, depending on
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1 the timing requirement or priority of the mission. And
2 you can't abuse your mutual aid neighbors with things
3 that can be handled a different way internally, and
4 shouldn't, shouldn't abuse those relationships, unless
5 absolutely necessary.
6 So from an urgency standpoint, I would say
7 that we would activate them in emergency situations
8 that had a timing-critical nature to them. If it
9 wasn't timing-critical, then we would access our own
10 resources to take care of that.
11 Q. So couldn't Pine-Strawberry then provide
12 coverage for 911/emergency call in CON 58 and have a
13 CON 58 ambulance go do the interfacility transport,
14 rather than have a Maricopa County ambulance do a
15 200-mile roundtrip trip --
16 A. Right.
17 Q. -- to pick up a patient in Payson and drive
18 it back?
19 A. Our preference is to try to run our business
20 the right way as much as possible, right. And that
21 would mean not counting on somebody who's got -- we've
22 got an agreement. And I would have to see the nature
23 of that agreement also, right, to understand what the
24 nature is.
25 But why would we bother them with stuff that
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1 we can handle ourselves? That doesn't make any sense
2 to me. I wouldn't engage a mutual aid partner when I
3 can handle that with my own service resources.
4 Q. But as far as CON 58 goes, you're technically
5 not handling it by yourself.
6 A. So if we're going to draw a CON line, it's
7 still part of our operation, our business, and it's not
8 our -- we don't have lines that say we don't cross here
9 because that's AMR Payson or that's CON 58, this is
10 Maricopa. That's not how we do things.
11 Now, primarily that's how we run our
12 business; but when we have an opportunity to do
13 something to help each other out and benefit each
14 other, absolutely. I would expect that we would do
15 that.
16 Q. So CON 58 really is just an extension of the
17 Maricopa County CONs that are to the south?
18 A. Well, I can't say in terms of CON. I don't
19 think that's an appropriate statement. But as far as
20 being able to help cover, we have resources and
21 neighboring CONs in areas that we absolutely will use
22 to our advantage to help make sure that our customers
23 are well-taken care of.
24 Q. So operationally, though, not for regulatory
25 purposes, but operationally, you look at CON 58 as an
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1 extension of the CONs in Maricopa County, from an
2 operational standpoint?
3 A. Not quite the way I would phrase it, I guess;
4 but in general, we try to work together as much as
5 possible, if we can, to help each other. It's not our
6 primary mission to be helping out each area a whole
7 bunch, right; but when those opportunities come up, I
8 think it would be a poor decision not to do that.
9 Q. So we talked earlier, and I think this is
10 correct. I don't think there was any misunderstanding
11 on this point. But when a non-CON 58 ambulance comes
12 in to provide one of those 368 interfacility
13 transports, first off, they're interfacility, but
14 even --
15 MS. FICKBOHM: And I am going to object,
16 because I don't think anybody testified that all of
17 those were interfacility. Some of those could have
18 been resources pulled up into Payson to back up the 911
19 system under a system status management plan. I don't
20 think anybody testified yet that those are all
21 interfacility transports.
22 ALJ SHEDDEN: All right. Mr. Meyerson,
23 is it your understanding that there has been that
24 testimony?
25 MR. MEYERSON: This is interfacility
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1 only, from my understanding, and we've been testifying
2 that this is interfacility only. I don't believe that
3 the reporting -- I don't believe that the reporting
4 requirement -- I would -- if they're pulling Maricopa
5 County ambulances up to do 911 calls, I guess I would
6 like to have some data on that. All we had available
7 to us was total interfacility.
8 ALJ SHEDDEN: All right. And the point
9 being that at this point the assumption is that you've
10 got -- what is it? -- Exhibit Hellsgate 15 on the
11 screen, and that's the little table that has, really,
12 just call numbers on there. It doesn't necessarily
13 give any more information than that. But the
14 assumption in your mind is these are all interfacility
15 transports, correct?
16 MR. MEYERSON: And not -- not calls.
17 They're actual interfacility transports.
18 ALJ SHEDDEN: All right. And
19 understanding that the exhibit itself doesn't
20 explicitly show that, correct?
21 MR. MEYERSON: That's correct.
22 ALJ SHEDDEN: All right. With that
23 clarifying information on the record -- well, let me
24 ask, Ms. Fickbohm, do you want to weigh in?
25 MS. FICKBOHM: No. I -- you know, I
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1 might have misunderstood the witness that had this in
2 front of them, but I didn't recall hearing anyone say
3 that this was exclusively IFT. If I'm wrong, I'm
4 wrong. And it doesn't say that, so it's confusing.
5 ALJ SHEDDEN: All right. So go ahead
6 and ask your question.
7 BY MR. MEYERSON:
8 Q. So the question was that these times are not
9 included in any sort of response time analysis; is that
10 your understanding?
11 A. I honestly don't know.
12 Q. So -- but you did say that when you determine
13 what resources are necessary for a system, that you do
14 track how long it takes for an ambulance to respond as
15 part of your analysis --
16 A. Sure.
17 Q. -- of whether or not more resources are
18 necessary in the area.
19 So did you run that analysis for these 368
20 calls in determining whether there were sufficient
21 resources?
22 A. I would assume that if these calls, in fact,
23 were run in the Payson area, that I would then have
24 that data included in that assessment, yes.
25 Q. And when you -- but you don't -- you didn't
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1 provide anything that shows us a breakdown or what
2 the -- what was it again, the -- let me find that.
3 I've got to use that term of art that you use, so I
4 want to make sure that I've got that right. It was the
5 load -- it was an acronym you used. I'm trying to find
6 it here. I made a note.
7 I think it's fairly important that I get that
8 correct, so give me one second while I find exactly
9 what that term was.
10 MS. FICKBOHM: Are you looking for OPAP?
11 MR. MEYERSON: I think it was the
12 average load hour or something to that effect.
13 THE WITNESS: I apologize. That's not
14 ringing.
15 BY MR. MEYERSON:
16 Q. Yeah, I'm sorry. Let me take a quick look.
17 A. Are we talking about workload? I could start
18 guessing, but --
19 Q. No, no, don't guess. I've got it here. I
20 just need to find it. I got off here.
21 Oh, average -- that's it. I apologize. It
22 was in one of my earlier questions. So the average
23 time on task.
24 Did you run an average time on task for these
25 368 interfacility transports?
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1 A. I don't know specifically on these calls.
2 But, again, assuming that these were all within the
3 body of run in Payson, so they would be part of our
4 Payson data set, they would be included in our
5 calculations for task time that we routinely do. It's
6 part of our daily efforts to keep an eye on task times.
7 Q. Okay. And so what I would like, because you
8 mentioned this as well, is that analysis that supports
9 your opinion that two providers can't coexist in
10 CON 58. Can you provide that?
11 A. I don't think that I testified to that. I
12 said sustainable, right. So you can have -- you can
13 have six providers in there. I don't think financially
14 that any of them will survive. The more you split it
15 out, the higher likelihood for all to fail.
16 Q. Well, I think that's saying another way what
17 I'm saying.
18 A. Okay.
19 Q. But you don't have any analysis? You just
20 think that based on what you've seen?
21 A. Okay.
22 Q. And, really, in the course of your testimony,
23 we don't have any reports or analysis that we can
24 review to support, really, anything that you said about
25 overstaffing, about average -- you know, average hour
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1 on task; none of that is supported by anything that is
2 reviewable. We just have to take your word for all of
3 your testimony here?
4 A. I suppose so. I'm under oath. I wouldn't --
5 wouldn't give you incorrect information.
6 Q. Okay. Thank you.
7 A. Not intentionally.
8 MR. MEYERSON: That's all I have.
9 ALJ SHEDDEN: Ms. Fickbohm, any
10 follow-up questions?
11 MS. FICKBOHM: Just a couple.
12
13 REDIRECT EXAMINATION
14 BY MS. FICKBOHM:
15 Q. Mr. Jones, when you run the OPAP data
16 platform, would it be easy for you to come in here and
17 show us all the information that's input to that, or
18 would that be a mountain?
19 A. That would be a mountain.
20 Q. And so, basically, I think I understand what
21 you're saying is that you take the CAD, all the CAD
22 data, the computer-aided dispatch data, and you put it
23 into this platform that you've already built, and then
24 you get the results out of it?
25 A. Correct.
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1 Q. When you -- you mentioned -- well, during the
2 lunch break, did you go back to get a precise answer to
3 a question that Mr. Ray asked you about how long CON 58
4 had been at a point where they could use the OPAP
5 platform?
6 A. Yeah. I think I earlier stated I thought it
7 had been about a year, and it hasn't been that long.
8 It was third week in June when we were on site doing
9 the training to deliver that OPAP tool. So closer to
10 six months.
11 Q. And you wanted to make that precise --
12 A. I did.
13 Q. -- information part of the record?
14 A. Because of that whole I took the oath thing,
15 and I certainly wouldn't intentionally provide wrong
16 information.
17 MS. FICKBOHM: Thank you.
18 ALJ SHEDDEN: Mr. Ray, anything?
19 MR. RAY: Nothing further.
20 ALJ SHEDDEN: Let me just ask a question
21 or two.
22
23 EXAMINATION
24 BY ALJ SHEDDEN:
25 Q. You used, maybe, two different terms
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1 regarding response time or -- one, you talked about out
2 of chute time.
3 A. Right.
4 Q. And then for the Hellsgate, though, you
5 talked about turnout time.
6 How do those differ?
7 A. My assumption is that we're talking about the
8 same thing, and they would have to validate that from
9 their perspective, since that was their report. But it
10 generally indicates the time -- I functioned in a
11 firehouse environment on the ambulance for many years.
12 And as I understood it, from their perspective, they
13 use turnout time the same way we use out of chute.
14 Q. Okay.
15 A. The time you get dispatched to the time you
16 actually physically get moving.
17 Q. All right. And then if I heard right when
18 you were answering some of Mr. Ray's questions, your
19 thought was that on the data only, the overstaffing, if
20 you will, was 60 unit hours per week; is that right?
21 A. That's a ballpark number, yes.
22 Q. Okay. How many unit hours per week total are
23 there now?
24 A. It's about 540.
25 Q. 540? Okay.
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1 ALJ SHEDDEN: And let me -- I probably
2 should have asked my questions before going back, but
3 we'll just go all the way around again. Any additional
4 questions, Mr. Meyerson?
5 MR. MEYERSON: Yeah, just a couple.
6
7 RECROSS-EXAMINATION
8 BY MR. MEYERSON:
9 Q. Would you agree with me that assuming that
10 out of chute data and turnout time, despite your
11 experience, could be different, based on dispatch
12 systems --
13 A. Certainly.
14 Q. -- how they measure it, how AMR measures it?
15 A. Yeah. I have no firsthand information on how
16 they measure that time.
17 Q. And then Ms. Fickbohm asked you a question
18 about what would the data look like if you were to
19 bring it all in here; but then she said something
20 that I think is my point, is you put it all into
21 the computer and it spits -- I mean I know that this
22 is --
23 A. I'm with you so far.
24 Q. -- a colloquialism. It spits out some
25 information that you could have summarized and
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1 submitted as an exhibit and then used for your
2 testimony; isn't that right?
3 A. I suppose we could have, yeah.
4 Q. Okay.
5 A. Yeah.
6 MR. MEYERSON: Thank you.
7 ALJ SHEDDEN: Mr. Ray, anything?
8 Ms. Fickbohm?
9 MS. FICKBOHM: No.
10 ALJ SHEDDEN: No, all right. Thank you,
11 sir.
12 THE WITNESS: Thank you.
13 ALJ SHEDDEN: All right. Who's
14 next?
15 MS. FICKBOHM: Alan Maguire.
16 ALJ SHEDDEN: Come on up.
17 Go ahead and have a seat. And I
18 don't think you got here before this afternoon.
19 I'm Administrative Law Judge Thomas Shedden. What
20 I'll do is get you sworn in, and then we'll follow
21 the same procedure we did with Mr. Jones there, all
22 right.
23 THE WITNESS: Okay.
24 ALJ SHEDDEN: If you would raise your
25 right hand.
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1 ALAN MAGUIRE,
2 called as a witness on behalf of the Intervenor herein,
3 having been first duly sworn by the Administrative Law
4 Judge to speak the truth and nothing but the truth, was
5 examined and testified as follows:
6
7 ALJ SHEDDEN: All right. Please state
8 and spell your name for our record.
9 THE WITNESS: My name is Alan Maguire,
10 A-L-A-N, M-A-G-U-I-R-E.
11 ALJ SHEDDEN: All right. And what you
12 may have missed coming in at the -- kind of the
13 midpoint with Mr. Jones is that we'll have
14 Ms. Fickbohm, who is, of course, the Life Line lawyer,
15 go first. So whenever you're ready, Ms. Fickbohm.
16 MS. FICKBOHM: Thank you.
17
18 DIRECT EXAMINATION
19 BY MS. FICKBOHM:
20 Q. Good afternoon, Mr. Maguire.
21 A. Good afternoon.
22 Q. Can you tell us what your current occupation
23 is?
24 A. Yes. I'm an economist and I run a public
25 policy consulting firm.
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1 Q. And as part of that public policy consulting
2 firm, do your regular duties include engaging in
3 economic forecasting?
4 A. Yes, they do.
5 Q. And tell me how long you've been -- well, let
6 me back up first.
7 Do you have any college degrees?
8 A. Yes. I have a degree in economics.
9 Q. And how long have you been involved in
10 economic forecasting?
11 A. Since the late 1970s.
12 Q. I see you're an original founding member of
13 the Arizona Western States and Metro-Phoenix Blue Chip
14 Economic Forecast Panel. What's that?
15 A. Well, the Blue Chip Forecast is -- actually,
16 the original one is a national survey that was
17 originally set up by an economist named Bob Eggert, who
18 was the retired economist for -- Mr. Eggert had been
19 the economist for many years at Ford Motor Company and
20 set up a national consensus forecasting process because
21 he had learned that many economists thinking together
22 come up with better results than a single economist
23 working alone.
24 Mr. Eggert, after he left Ford, retired to
25 Sedona, Arizona. Mr. Eggert and I became friends. We
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1 worked together on several projects. And there was an
2 interest in creating a forecast in Arizona similar to
3 the National Blue Chip Forecast.
4 So he and I set up the original Arizona Blue
5 Chip Forecast, recruited about a half a dozen,
6 initially, people to join us over time, and now it's
7 been going on ever since. I think that was 1982 or
8 thereabouts. That's been going on ever since, and it
9 has spread now. The Arizona State University took it
10 over after a period of time, and they now do it for the
11 Western States. So the methodology has been copied in
12 California, Washington, Nevada, et cetera.
13 Q. Sort of going sequentially or talking about
14 what you've done, your resumé says you've served as an
15 economic, fiscal and policy advisor to several Arizona
16 Governors?
17 A. Yes.
18 Q. And other State Representatives.
19 Approximately when did that begin?
20 A. So beginning in the late 1970s, I was the
21 senior economist for the Arizona State Senate. I
22 worked for both the Democrat Majority and the
23 Republican Majority during that period of time.
24 I left that position and became the Chief
25 Deputy Treasurer in the State of Arizona. Throughout
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1 that period of time, I conducted detailed analyses of
2 fiscal systems within the State of Arizona, including
3 the formation of local government agencies and
4 operations.
5 After I left that, I went on and was an
6 investment banker, doing public finance, municipal
7 finance in the state of Arizona. And that included,
8 also, forecasts for local governments, both economic
9 forecasts as to their local conditions, as well as
10 revenue forecasts for them for their upcoming budgets.
11 And since initially 1986, but ultimately
12 1991, I've been doing the same thing as a consultant,
13 during which period of time I have had the good fortune
14 to work with multiple State agencies, including all the
15 large agencies that do forecasting, Counties across the
16 state of Arizona, Cities across the state of Arizona,
17 and a number of various Special Districts over time.
18 Q. And is that background of yours further
19 detailed in your biographical sketch that we have up in
20 front of you as Exhibit 13k?
21 A. It is in brief, yes.
22 MS. FICKBOHM: I move for admission of
23 13k.
24 MR. MEYERSON: No objection.
25 ALJ SHEDDEN: All right. 13k is
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1 admitted.
2 BY MS. FICKBOHM:
3 Q. Mr. Maguire, were you asked by Life Line
4 Ambulance to review facts relating to your making an
5 economic forecast for Fire Districts in the state of
6 Arizona, in particular those holding certificate of
7 necessities and including the Hellsgate Fire District?
8 A. We did an analysis of the reported data to
9 the Department concerning the operations of ambulance
10 services across the state of Arizona operating under a
11 CON that provided significant information; and on the
12 basis of that data, we were able to draw some
13 conclusions.
14 Q. Okay. We'll break that down in just a
15 second.
16 So you were asked to perform that task?
17 A. Yes.
18 Q. Okay. And can you tell me how you've been
19 compensated for your time on this project?
20 A. Yes. I'm being paid a fee of $5,000 for this
21 expert witness work.
22 Q. Okay. In the information that you considered
23 for this project, did it include the compilation of the
24 tax rates for 2014 and 2015, with emphasis or
25 demarcation of Districts providing ambulance service,
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1 as represented in LLA Exhibit 9?
2 A. Yes, we looked generally at tax rates for
3 Fire Districts over the last several years, and this is
4 an evidence of that.
5 Q. And this was part of what you considered?
6 A. Yes.
7 Q. And that was provided to you by Mr. Kasprzyk?
8 A. Yes.
9 Q. Tell us what else, besides LLA-9, you looked
10 at as facts in order to perform the tasks that you
11 performed?
12 A. As I mentioned, we looked at the reports
13 routinely submitted to the Department.
14 Q. I'm sorry, you're going to have to slow down
15 for me too.
16 A. Okay. I apologize to both of you.
17 We looked at the reports that are routinely
18 submitted to the Department. In some cases the reports
19 had gaps in them, and so we couldn't consider them; but
20 by and large, the vast majority of them were complete
21 and allowed us to do some analysis and draw some trends
22 from those reports.
23 Q. And, now, what reports are you referring to?
24 A. The ARCRs.
25 Q. Okay. ARCRs submitted by Fire Districts?
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1 A. Right.
2 Q. Did you review the pro forma ARCR submitted
3 by Hellsgate Fire District?
4 A. Yes, we did.
5 Q. Did you review their annual financial
6 information submitted as part of this process?
7 A. Yes, we did.
8 Q. Did you review the findings that the Bureau
9 of Emergency Medical Services made as part of their
10 analysis of Hellsgate's application for a CON?
11 A. Yes, we did.
12 Q. Anything else that you dug in to look at?
13 A. We looked at other material that was out
14 there. For example, we looked at tax rates as
15 published by the Arizona Tax Research Association,
16 which align with the data that's in the exhibit before
17 you.
18 Q. And did you then apply your experience and
19 knowledge gained since the late '70s in the area of
20 economic forecasting to perform your work on this
21 project?
22 A. Yes, we did.
23 Q. So can you tell us what you see, as an
24 economist, as historic trends for Fire Districts that
25 hold CONs in Arizona, just in general?
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1 A. So generally speaking, what we learned was
2 that most of the ambulance services operated by Fire
3 Districts tend to operate at an annual loss, based upon
4 the data in the reports that they file.
5 We also learned that it appears that based
6 on, again, the reports, that they have a higher average
7 share of their expenses derived from personnel-related
8 expenses. That's not surprising. They are able to
9 maintain themselves by virtue of the fact that they can
10 use their general revenues to cross-subsidize their
11 operations.
12 And they also tend to have a lower number of
13 trips per employee. And they are able to maintain that
14 operation over time because of that cross-subsidy that
15 comes from their general fund, which is largely
16 supported from their property taxes, one of the major
17 sources that allows Fire Districts to operate.
18 And many of them, including Hellsgate, as a
19 matter of fact, are at their statutory cap of $3.25,
20 and that's been an issue for Fire Districts generally
21 in Arizona for a number of years.
22 Q. And looking at the historical data, how do
23 you believe what you see as those trends impacts the
24 future outlook for Arizona Fire Districts holding CONs?
25 What's the economic forecast for that class of
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1 entities?
2 A. Right. I think that the challenges that Fire
3 Districts operating ambulance services face is the fact
4 that they tend to operate at a loss, and they use the
5 cross-subsidy through their general funds to maintain
6 that service.
7 And there's no reason to believe, because of
8 the categorical commonalities of Fire Districts in
9 Arizona, that they -- that Hellsgate would be any
10 different than the other ones.
11 Q. So, in your opinion, is certificate of
12 necessity acquisition a financial plus or a
13 negative?
14 A. Well, based on the fact that the majority of
15 Fire Districts that operate ambulance services have to
16 cross-subsidize because they have a loss in their
17 ambulance services, it is very likely -- no one can be
18 positive, but it's very likely that Hellsgate could, in
19 fact, adversely affect their financial condition.
20 Q. And plugging that into what you saw as their
21 current financial condition vis-à-vis how much they
22 tend to maintain for cash reserves, what would your
23 economic forecast for them be?
24 A. Hellsgate appears to be a very well-run Fire
25 District. They have cash balances that range in the,
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1 you know, about three-quarters of a million dollars
2 from year to year. That's better than a lot of Fire
3 Districts, frankly. But that's because of the
4 operations that they're running right now.
5 If they were to take on an operation that
6 costs them -- that caused them to have a loss, that
7 cash surplus, that available liquid reserve would be
8 endangered. And depending how big the annual loss is,
9 that would be a greater or lesser danger to them.
10 Q. Are you aware of the recent Arizona Supreme
11 Court decision relating to Public Safety Pension
12 payments?
13 A. Yes, I am.
14 Q. And can you speak to how that decision could
15 impact the economic forecast for any Fire District in
16 Arizona?
17 A. Well, what the Court did in, actually, a
18 series of decisions, the most recent one being just
19 very recently, was constrain the ability of employers
20 to modify the contribution rates made by employees to
21 support the defined benefit contribution system through
22 the Public Safety Retirement System.
23 The fundamental challenge that the Public
24 Safety Retirement System faces is that it has a very,
25 very large unfunded liability that has accrued over
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1 many years from past service, where insufficient funds
2 were set aside to offset that liability, and the
3 expected rate of return on the available assets was
4 less than expected.
5 The consequence of those is that their
6 unfunded liability has grown. The contribution rates
7 have grown. And so, essentially, the cost per employee
8 has risen for operators.
9 Q. And if I already asked you this, I apologize.
10 But as you looked at the data, including Hellsgate's
11 application and its finances, did you see any reason to
12 believe that the Hellsgate Fire District's experience
13 with the financial implications of holding a
14 certificate of necessity are going to be any different
15 than other Fire Districts that have certificates of
16 necessity?
17 A. We saw no evidence of that fact.
18 Q. Thank you, Mr. Maguire.
19 MS. FICKBOHM: That's all I have, Your
20 Honor.
21 ALJ SHEDDEN: All right. Mr. Ray,
22 anything?
23 MR. RAY: I have no questions,
24 Judge.
25 ALJ SHEDDEN: All right. Mr. Meyerson.
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1 CROSS-EXAMINATION
2 BY MR. MEYERSON:
3 Q. You mentioned a few items that you reviewed,
4 which it sounds -- were those provided by Ms. Fickbohm?
5 A. Other than the exhibit here, no.
6 Q. And the information that you reviewed didn't
7 consider management or different staffing models; is
8 that right?
9 A. It did not.
10 Q. And the findings letter that was provided to
11 you, was that an assumption that you made that the
12 findings letter was the correct information for
13 purposes of your analysis?
14 A. I'm sorry. Which letter?
15 Q. The findings letter. She said that -- sorry.
16 Ms. Fickbohm said that one of the items you reviewed
17 was the findings letter. You can go to it, if you
18 would like.
19 It looks like Ms. Fickbohm is getting --
20 pulling it up now.
21 Does this look familiar to you?
22 A. Yes. So you mean the findings letter
23 submitted by the Department to the applicant.
24 Q. Yes. And so was the information you reviewed
25 and determined was accurate the applicant's proposal or
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1 the Department's proposal for purposes of determining
2 if the applicant could sustain operations of an
3 ambulance service?
4 A. Right. The letter from the Department to the
5 applicant indicates that they believe that their
6 charges are insufficient, and that even with the
7 adjusted charges, they would have a loss.
8 Q. So you used the Department's proposed rates
9 for purposes of your analysis?
10 A. Well, it certainly appears that the findings
11 of the Department are consistent with the experience
12 evidenced in the reports from other Fire Districts
13 across the state.
14 Q. So you did use the proposed rates by the
15 Department?
16 A. In part.
17 Q. And then you said another thing and then
18 contradicted yourself a second after that. You said
19 "due to the categorical commonalities." And maybe
20 that's a technical term, but in my mind, when I hear
21 "categorical commonalities," it means every Fire
22 District is the same.
23 Is it common for Fire Districts to have
24 available capital of approximately a million dollars?
25 A. It depends on the size of the District and
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1 their financial standing.
2 Q. And then the losses from ambulance operations
3 that you referred to a second ago, I think the
4 testimony was, based on an analysis of most of the Fire
5 Districts in Arizona that operate their ambulance
6 services at a loss, you would have to assume that
7 Hellsgate would also operate at a loss.
8 That's a fairly broad statement, don't you
9 think, without looking and drilling down closer and
10 asking specific questions to Hellsgate?
11 A. So we know that Fire Districts have the same
12 structure across the state. They have the same
13 principal revenue sources. They have the same
14 principal employment agreements. They have the same
15 general common characteristics. There's very little
16 that differentiates them, except for their particular
17 location and the particular tax base that they happen
18 to have.
19 And so it's a fair assumption, I believe,
20 that if you look at a wide range of Districts that have
21 general commonalities in common, that they will act
22 similarly. That's based upon working with local
23 governments for 40 years.
24 Q. Yet they, in some way, by having available
25 capital of a million dollars, are you aware of any
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1 other Fire Districts in the state of Arizona that have
2 available capital of that amount?
3 A. So those are two different questions. With
4 regard to the operation of Hellsgate as a Fire
5 District, that capital balance has been -- has been
6 developed and has been relatively stable at least over
7 the least three financial statements that I looked at;
8 and as a consequence, any change -- material change to
9 their operations could either increase that balance or
10 decrease that balance.
11 Q. Correct. But that was based on the
12 assumption that the ambulance services are operating at
13 a loss?
14 A. That's correct.
15 MR. MEYERSON: That's all I have, Your
16 Honor.
17 ALJ SHEDDEN: Ms. Fickbohm, anything
18 else?
19 MS. FICKBOHM: No.
20 ALJ SHEDDEN: Mr. Ray?
21 MR. RAY: Nothing, thank you.
22 ALJ SHEDDEN: All right. Thank you,
23 sir.
24 All right. Who will be next?
25 MS. FICKBOHM: Mr. Bartus.
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1 ALJ SHEDDEN: All right. Let me give
2 you a minute to get ready.
3 Ready?
4 THE WITNESS: Thank you.
5 ALJ SHEDDEN: Let me get you sworn in.
6
7 RICHARD BARTUS,
8 called as a witness on behalf of the Intervenor herein,
9 having been first duly sworn by the Administrative Law
10 Judge to speak the truth and nothing but the truth, was
11 examined and testified as follows:
12
13 ALJ SHEDDEN: All right. Go ahead and
14 state and spell your name for our record, please.
15 THE WITNESS: Richard Bartus, last name
16 B, as in boy, A-R-T-U-S.
17 ALJ SHEDDEN: All right. Whenever
18 you're ready.
19 MS. FICKBOHM: Thank you, Your Honor.
20
21 DIRECT EXAMINATION
22 BY MS. FICKBOHM:
23 Q. You stated your name for the record. Can you
24 tell me what your current occupation is?
25 A. I'm currently the regional operations and
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1 finance officer for the South Region of American
2 Medical Response, which encompasses the state of
3 Arizona.
4 Q. On a parallel with performing that job, have
5 you recently received another job title?
6 A. Yes. I am in the process of transitioning to
7 an executive vice president role with the organization.
8 Q. Congratulations.
9 A. Thank you.
10 Q. I think.
11 Let's talk about how you came to emergency
12 medical services and the path that your career has
13 taken.
14 First of all, do you have a college degree?
15 A. Yes. I have a Bachelor's degree, emphasizing
16 in accounting, from Temple University.
17 Q. And when did you first start working in the
18 emergency medical services field?
19 A. September of 1992.
20 Q. And how did that come about?
21 A. Like most people that have been in the
22 business for well over 20 years, a lot of people just
23 happen to fall into it.
24 I fell into some of the front-line work
25 through a mutual friend. Got started in the ambulance
COASH & COASH, INC. 602-258-1440 www.coashandcoash.com Phoenix, AZ
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1 business working in fleet maintenance, of all places.
2 Eventually migrated over to the operations side and
3 working in the communications center, both as a
4 dispatcher and call-taker, eventually receiving my EMT
5 certificate from the Commonwealth of Pennsylvania
6 shortly thereafter.
7 And after a few years of working both field
8 and communications-related jobs, worked my way into the
9 financial and accounting division --
10 Q. And approximately --
11 A. -- for the AMR locations.
12 Q. And approximately when was that?
13 A. In October of 1994, I transitioned to the
14 business side of the ambulance business.
15 From 1994 all the way up through present,
16 I've worked in various regional and corporate level
17 roles, rising up through the ranks as between
18 accounting supervisor, corporate accounting manager,
19 regional director, and then ultimately into various
20 executive roles as regional corporate vice president
21 roles.
22 Q. And you've also -- you're not just a finance
23 guy; you also have run operations?
24 A. Yes, for a period of time I did perform
25 day-to-day oversight with various operations as a
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1 divisional and regional chief operating officer.
2 Q. And for the last -- now I'm going to show. --
3 seven years or so, have you been gaining experience in
4 the Arizona ambulance transport market?
5 A. Yes. It was about eight years.
6 Q. Eight years.
7 A. From the AMR acquisitions with River Medical
8 back in 2008, acquisitions of Life Line Ambulance just
9 a few years ago, maybe three.
10 Q. And when you say "Life Line" -- excuse me,
11 for interrupting. -- then what was Life Line? It was
12 located in --
13 A. Located in Prescott --
14 Q. Okay.
15 A. -- Arizona.
16 And that was just a few years ago. So
17 starting in 2008 I began to get exposure to the Arizona
18 regulatory environment, which included the regulatory
19 requirements for the annual revenue and cost report.
20 Q. Which is we continually refer to as the
21 ARCRs?
22 A. The ARCRs, correct.
23 Q. So are you the person who's been preparing
24 the ARCRs for River Medical, now known also as one of
25 the Life Line members, since its acquisition by
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1 American Medical Response in 2008?
2 A. Yes, I have personally prepared those ARCRs
3 myself over the last eight years.
4 Q. And subsequent to American Medical Response's
5 acquisition of Life Line in Prescott a few years ago,
6 have you been preparing -- or have you been putting
7 together the ARCR reporting for that organization?
8 A. Yes, I have personally prepared and signed
9 the ARCRs for the Life Line organization out of
10 Prescott.
11 Q. And subsequent to AMR getting a certificate
12 of necessity in Maricopa County, have you filed at
13 least one ARCR for that entity?
14 A. Yes, I did personally prepare the ARCR for
15 CON 136 for AMR of Maricopa.
16 Q. And that -- they've just filed one, correct?
17 A. Correct, we filed our first ARCR for calendar
18 year 2015. Yes, 2015.
19 Q. And in addition to filing ARCRs, do you also
20 have managerial oversight of billing and collections?
21 A. In addition to filing the ARCRs, I've also
22 prepared pro forma ARCRs. So I would like to make sure
23 the record reflects that I've prepared numerous
24 pro forma ARCRs as well.
25 Q. So in connection -- thank you for that
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1 clarification.
2 In connection with the acquisition of River
3 Medical, Life Line Prescott, and the CON in Maricopa
4 County, you're the person who prepared the pro forma
5 ARCRs for each of those?
6 A. Yes, I did prepare those.
7 Q. Do you also look at the data coming out of
8 Arizona regarding billing and collections?
9 A. Yes. While I don't have direct oversight of
10 the billing and collections personnel, it is part of my
11 duties to routinely review in depth billing detail in
12 the production of the ARCR.
13 Q. And as part of your duties, are you required
14 to keep up to date on change in Medicaid/Medicare
15 compensation?
16 A. Yes. Not only is it part of our day-to-day
17 in the performance of the job, but it is part of our
18 annual strategic planning when it comes to budget
19 forecasting and understanding upcoming changes in
20 reimbursement.
21 Q. And as part of your annual budget
22 forecasting, do you also look at trends in collection
23 and billing rates?
24 A. We look at trends in billing rates. We look
25 at trends in payor mix. We look at levels of service,
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1 whether there's changes in the mix, whether it's
2 advanced life support or basic life support, whether
3 they are emergent or nonemergent in nature, various. A
4 lot of those indicators could impact your trends, which
5 ultimately will impact your future collections.
6 Q. And when you use the term "payor mix," what
7 does that mean?
8 A. It's understanding of the amount of
9 transports you have, what percentage is routinely
10 billed to Medicare, what percentage would routinely be
11 billed to Medicaid, third-party insurance, and even a
12 percentage of transports where patients have no
13 insurance.
14 MS. FICKBOHM: Your Honor, I would move
15 for admission of LLA-13b.
16 MR. MEYERSON: No objection.
17 ALJ SHEDDEN: All right. 13b is
18 admitted.
19 MS. FICKBOHM: This is where
20 LLA Exhibit 27 isn't showing up.
21 ALJ SHEDDEN: Right. This has not yet
22 been copied over. Hang on.
23 MS. FICKBOHM: There it is.
24 ALJ SHEDDEN: This one on the screen I
25 copied over. And I will let folks know, if there's a
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1 preference, it is on the internet version. It's been
2 updated to our docket, but I'll leave it to you folks
3 if you're content with the one that I made the
4 electronic copy and copied to this computer. This
5 is -- and it looks like this one's still showing the
6 labeling error, because it's showing it as
7 Hellsgate 27. So let me get the --
8 MS. FICKBOHM: But the document itself
9 is marked as -- okay. You're right, it is. Yeah.
10 ALJ SHEDDEN: Hang on and I'll get
11 the -- so now I've got the internet open and we're on
12 the electronic docket for this hearing. You'll note,
13 perhaps, that that version has been updated to show the
14 exhibits that had been admitted as of yesterday, and
15 then Life Line 27 is appropriately marked on there and
16 is on the screen.
17 MS. FICKBOHM: Thank you for that
18 assistance, Your Honor.
19 BY MS. FICKBOHM:
20 Q. Mr. Bartus, we have before us LLA Exhibit 27.
21 Is this something that you prepared?
22 A. Yes, I did prepare this document.
23 Q. And I'm not going to pull up the earlier
24 version, but you did an earlier version of this that
25 you corrected?
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1 A. Yes, I did. I believe that was AMR or Life
2 Line 16.
3 Q. And can you -- does this exhibit show where
4 the corrections were? And feel free to move around
5 there.
6 A. Yes. One of the advantages of using color,
7 like I like to do, is to be able to point out things
8 like that. I did color-code and add a legend for the
9 Court's benefit of understanding things that I may have
10 changed.
11 The items I labeled in purple were some
12 things that I had, upon second review, felt that I had
13 a formula error in one cell that drove a handful of
14 calculations. So I thought it was important to change
15 those numbers and accurately reflect my analysis.
16 The one number I did change is reflected here
17 on Page 4 relating to the increase in accounts
18 receivable in the cash flow statement, which did impact
19 a couple line items on the balance sheet.
20 Q. And so you changed the individual line item,
21 but there may be -- the totals underneath those will
22 also change?
23 A. Yes. I did not go through and highlight each
24 one of those, but, yes, it is with that notion.
25 Q. Oops, I'm making it -- that would be cruel.
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1 Okay. So can you tell us how you went about
2 putting this document together and what your intended
3 purpose of it was?
4 A. Sure.
5 This document represents a comparison of the
6 applicant's proposed ARCR, the Bureau's proposed
7 findings, which were --
8 Q. The second column?
9 A. -- would be the second column that is colored
10 and labeled BEMSTS Proposal. Those findings were
11 ultimately accepted by the applicant.
12 The next section is labeled the 2015 ARCR for
13 CON 58. And my purpose was generally to do a
14 comparison of the three sets of figures in order to
15 understand whether the pro forma proposed by the
16 applicant was achievable and reasonable.
17 Q. So you -- your intent was to compare the
18 first three columns of the first page of Exhibit 27?
19 A. That's correct.
20 Q. And where did you obtain the information that
21 you used to do this?
22 A. Through the publicly available documents with
23 this hearing.
24 Q. So tell us what the first comparison was that
25 you did.
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1 A. First comparison I've labeled sort of with an
2 A up at the top.
3 Q. We're still on Page 1?
4 A. We're still on Page 1, correct.
5 It says CON 58 Actual 2015 Revenue With
6 Applicant/Bureau Proposed Expenses.
7 Q. So what does "Applicant/Bureau Proposed
8 Expenses" mean?
9 A. The Bureau, in their analysis, in their
10 findings, with the exception of bad debt, concurred
11 with the expense proposal with the applicant. So I am
12 not intimately involved with Hellsgate's fire expenses,
13 so I have to presume at this point that those expenses
14 are true and accurate and is what is expected for them
15 to incur in the performance of services.
16 Q. And why did you want to compare their
17 expenses with CON 58 actual 2015 revenue?
18 A. Well, being that we have the experience of
19 the approximately 3,000 transports in the CON area, I'm
20 very confident that, you know, we, you know, have
21 maximized the revenue opportunity in that CON area.
22 And given that the applicant has proposed to displace
23 CON 58, my presumption is that despite their
24 projections and our experience in collecting in that
25 area, that based on our 2015 report, there is only
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1 $2,986,000 worth of revenue to obtain.
2 Q. And so what was your ultimate conclusion in
3 doing that comparison?
4 A. My conclusion, that if you utilize our
5 revenue experience, coupled with the proposed operating
6 expense structure from the applicant, that the proposed
7 applicant will lose a little more than $575,000 in its
8 first year of operation.
9 Q. And that's what's showing down at the very
10 bottom of your fourth column on Page 1?
11 A. That is correct.
12 Q. Labeled A.
13 What comparison did you do in Column B?
14 A. Column B I just wanted to test the revenue
15 and bad debt based on the Bureau's proposed rates and
16 charges that have the higher base rate of $1,727 and
17 the smaller mileage rate of $10.97.
18 Q. So you compared the -- you compared Hellsgate
19 pro forma that's the amount -- that's the rate that the
20 Bureau was allowing them with the -- with what?
21 A. In the -- the last column does that
22 comparison, essentially, Section B.
23 Q. Oh, so I'm sorry. So in Column B, is that a
24 comparison or you're just restating it?
25 A. I'm restating the revenue based on the
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1 Bureau's proposed rates and charges structure.
2 Q. So Column B is not a comparison; it's just
3 restating?
4 A. It's restating, and, really, it was an
5 analysis to show that the revenue -- gross revenue
6 proposed by the Bureau would have no material impact on
7 the net revenue achieved by the applicant.
8 Q. Okay. So this isn't a restatement of the
9 Bureau's findings. This is applying -- as opposed to
10 using CON 58's allowed rate, you used the rate allowed
11 by the Bureau?
12 A. Correct, again, to show that there is no
13 material impact in what the rates the Bureau has
14 proposed.
15 Q. And your final column there, A compared to B,
16 is doing exactly that, correct?
17 A. Correct. It just shows that despite the
18 different rates and charges, in the end there's no
19 material change in the operating revenue, whether it's
20 the rates proposed by the Bureau or the rates proposed
21 by the applicant.
22 Q. There's basically a $3,049 difference between
23 the two?
24 MR. MEYERSON: I'm going to object to
25 the line of questioning. All the questions she's
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1 asking are leading the witness.
2 ALJ SHEDDEN: Well she's asking -- you
3 know, and I've got to admit, I was struggling before to
4 the exception to allow background. We're looking at
5 the exhibit.
6 So the objection's overruled. And,
7 again, to the extent any leading question is asked,
8 there's really little that can be done other than
9 determine what weight can be given to the answer.
10 BY MS. FICKBOHM:
11 Q. And, Mr. Bartus, can you tell us why there
12 isn't a significant difference if you change the rate?
13 A. Yes. Because at the end of the day, the
14 payor mix is still the payor mix. There are so many
15 Medicare calls. Regardless of what you charge, you're
16 going to get paid the same Medicare rate, as various
17 witnesses have testified already. You're going to get
18 paid the same rate from AHCCCS, regardless of the rates
19 and charges, although AHCCCS does move with the rates
20 and charges.
21 Since the Bureau has adjusted the $1,727 rate
22 as a means of offsetting the lower mileage rate, in
23 total there is really no major change in revenue, and
24 it will not change AHCCCS reimbursement as well.
25 Q. Can you go to Page 2 and tell us what you did
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1 there.
2 A. Page 2, I did not perform any detailed
3 analysis other than, for my benefit, have a means of
4 doing a side-by-side comparison in understanding the
5 different line item expenses.
6 Q. So can you just start at the top and tell us
7 what the three different columns are?
8 A. Sure. The three columns, again, were
9 comparing the applicant's proposed operating costs
10 compared to the Bureau's proposed operating costs, and
11 then the third column lists the operating costs of the
12 certificate holder CON 58.
13 Each of the, if you will, row structures
14 correspond to the ARCR categories for wages, payroll
15 taxes and benefits, general and administrative
16 expenses, cost of goods sold, as well as other
17 operating expenses.
18 Q. And the first column is based on what? When
19 you say "applicant's proposed," where did you get those
20 figures from?
21 A. That came from their pro forma ARCR in their
22 application. I'm sorry, the revised pro forma; not the
23 original one that was in the application that had a
24 higher income number. The second column, the Bureau's
25 Proposed, was from their findings. And the third
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1 column, CON 58, was our actual ARCR filed for 2015.
2 Q. And what does the comparison demonstrate to
3 you?
4 A. Primarily, the major difference between the
5 three revolves around wages, taxes, and benefits. And
6 it is not uncommon to see that large of a gap between a
7 private provider and a Fire District provider, and I
8 believe Mr. Maguire had offered testimony on that
9 already.
10 Q. Take us to Page 3, and let us know what we're
11 looking at here.
12 A. Page 3 is a comparison of the balance sheet.
13 Column 1 is the applicant's proposed balance sheet.
14 Column 2 is a balance sheet that I had calculated based
15 on the Bureau's findings letter.
16 Q. DHS Exhibit 9?
17 A. That's correct.
18 Q. And when you say "Balance Sheet, Page 15,"
19 this is a -- can you tell us what that is?
20 A. Page 15 is the page number in the required
21 ARCR documents, where Page 15 you have to supply the
22 projected balance sheet for the pro forma period.
23 Q. Okay. So tell us what we have here.
24 A. So Column 1, when I analyzed the applicant's
25 proposed balance sheet, I noted a couple items in
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1 yellow that I was not sure on what they represented.
2 The first one is the accounts receivable
3 number of $588,574. Normally, in the first year of
4 operation for a start-up, that number usually will flip
5 back to a line item in your cash flow statement. And
6 that number did not tie to a number in the cash flow
7 statement in terms of the working capital impact for
8 accounts receivable.
9 And I believe Mr. Taylor testified yesterday
10 that there was additional Fire District AR that he
11 included in this to explain why those would not match.
12 Q. And when you're doing an ARCR reporting to
13 the Bureau, do you include income from operations other
14 than the ambulance transport operation?
15 A. It's my understanding that it is solely the
16 ambulance operation that's included in the ARCR.
17 Q. So if you were doing an ARCR for a Fire
18 District, a pro forma ARCR, would you include trailing
19 accounts receivable that the Fire District has for its
20 other services, non-ambulance services?
21 A. No, I probably would have treated this ARCR
22 as sort of like a start-up that shows, you know, zero
23 cash and really show the cash infusion coming from the
24 District versus existing cash on hand, just to sort of
25 be transparent that it's a new venture and that it
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1 should be treated as a new venture; and, thus, it would
2 be more applicable to, you know, like a brand-new
3 company.
4 Q. Anything else you noticed in looking at the
5 ARCR Page 15 balance sheet that's reflected in the
6 first column on Page 3 of Exhibit 27?
7 A. Just two other things. One, I noticed there
8 was no inventory amount in the ARCR. Income statement
9 reflected that there would be an end-of-year inventory
10 of $40,000, so I did not see that noted on the balance
11 sheet.
12 And then the last item was, I believe,
13 referenced yesterday during Mr. Taylor's testimony,
14 $59,115 on Row 18. It was an item that he did not
15 identify in his pro forma ARCR.
16 Q. What do you mean, he did not identify?
17 A. There was no description under Current
18 Liabilities of what that liability represented.
19 Q. And did he tell us what that is?
20 A. I believe he did. I can't exactly quite
21 recall his exact words.
22 Q. What's Column No. 2?
23 A. Column No. 2 is a pro forma balance sheet
24 that I prepared using the findings information that the
25 Bureau had prepared. The Bureau did not prepare a
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1 balance sheet, but a balance sheet can easily be
2 prepared through -- from applying their findings
3 information. So Column 2 represents that if a balance
4 sheet was to have been prepared as a result of the
5 Bureau's findings, Column 2 represents what I believe
6 the balance sheet would have looked like.
7 Q. And the bottom line for 1 as compared to 2,
8 is that a calculation that you made?
9 A. Yes. Essentially, the major difference
10 between the two was a result of my projected net income
11 of a loss of $575,000, and using the -- I'm sorry, it
12 was the Bureau's findings of $251,000. That using the
13 Bureau's findings of a loss of $251,000, which the
14 applicant did concur with, the largest impact would
15 have been in the fund balance and cash line items,
16 showing that the loss would have a drain of cash in
17 their remaining fund balance.
18 Q. And is there anywhere in this that you can
19 show us the difference between those two?
20 A. Could you say that --
21 Q. I'm sorry. What's the third column show us?
22 A. Sure. The third column is based on my
23 pro forma calculation of using our actual revenue
24 experience with their proposed operating costs that
25 showed a loss of $575,000. I had prepared a pro forma
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1 balance sheet here to show the sections that would be
2 impacted if the District incurred such a loss, and,
3 again, it's primarily cash and fund balance. And those
4 differences are represented in the far right column,
5 where it says "3 minus 1," Column 3 minus Column 1, as
6 the "Pro Forma v Applicant."
7 Based on my, again, pro forma review, I
8 believe that the cash and fund balance would have a
9 material impact, to the tune of approximately $575,000,
10 after its first year of operation.
11 Q. That's the bottom line number in the green
12 column?
13 A. Correct.
14 Q. And we didn't -- I'm not sure if we discussed
15 the blue column or not. Tell me what that shows.
16 A. The blue column was, just a few minutes ago
17 we talked about how the primary change was because the
18 Bureau had concluded that the applicant will lose
19 $251,000. So if we had applied the Bureau's findings
20 to a balance sheet, Column 2 would be the projected
21 view of that balance sheet.
22 Q. And does -- is 2 to 1 a comparison or -- the
23 blue column.
24 A. Yes, the blue column, 2 to 1, that is,
25 "2 minus 1," is basically showing the difference
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1 between the applicant's proposed balance sheet and what
2 a balance sheet would have looked like using the
3 Bureau's findings.
4 And, again, the difference being that the
5 Bureau is projecting a $250,000 loss versus a $30,000
6 income figure the applicant has proposed.
7 Q. So tell me again the difference between the
8 column that you've numbered 1, Applicant Proposed.
9 That's off of their ARCR?
10 A. That is correct.
11 Q. And then Column 3, Hellsgate Pro Forma, how
12 is 3 different from 1?
13 A. Column 3 is what I had prepared, again, using
14 the actual revenue experience of CON 58 against the
15 proposed expenses by the District.
16 If the application had reflected a $575,000
17 loss, it is my estimation that Column 3 would have been
18 the balance sheet that would have been proposed in the
19 ARCR by the applicant.
20 Q. And turning to Page 4, what calculations did
21 you do here?
22 A. Page 4 is a comparative analysis of the cash
23 flow statement that is supplied as Page 16 of the ARCR.
24 Q. And does a cash flow statement show us?
25 A. Well, a cash flow statement will show, you
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1 know, the primary categories that account for your cash
2 balance change during the year. So in any given year
3 you will see your accounts receivable grow or decline,
4 and that will indicate what your movement in cash was
5 as a result of the accounts receivable. It will also
6 show positive or negative movements in your liabilities
7 that show you how well you managed your cash outflow.
8 In addition to that, it will show other
9 long-term financing activities, as well as capital
10 investments into your operation.
11 It is merely intended to, you know, give any
12 reviewer of the document an opportunity to understand
13 how you spend your money and how well you manage your
14 accounts receivable and accounts payables.
15 Q. So you have a bright yellow shading that your
16 legend says "Appears to be incorrect or missing." So
17 explain what that is here.
18 A. Sure.
19 Column 1, again, in a similar format as the
20 balance sheet that was on the previous Page 3, I listed
21 the applicant's proposed cash flow statement, as well
22 as various other calculations that I performed.
23 I noted in the applicant's proposed cash flow
24 statement that, again, the income statement indicated a
25 $40,000 inventory balance at the end of the year, so I
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1 would have expected to see a negative $40,000 inventory
2 number in the cash flow statement.
3 Q. At Line 6?
4 A. On Line 6. Because the District would have
5 paid that 40,000 in cash to establish a supply
6 inventory for the ambulances.
7 Q. So that's missing?
8 A. So that appears to be missing.
9 Q. Okay. And then the next yellow block where
10 there is no information, what would you have expected
11 to see there in Column 1?
12 A. In Column 1, with respect to accounts payable
13 and accrued expenses, again, being that the
14 ambulance -- the proposed ambulance operating structure
15 for the District would have resulted in increased
16 operating costs, I would have expected to see a
17 positive impact to cash as a result of the normal delay
18 in paying your expenses.
19 You know, as an example, accounts payable
20 normally has 45-day payment terms. So while you may be
21 incurring a liability, the cash isn't leaving the door
22 for 45 days. So that would have been a positive effect
23 to the applicant's cash flow statement.
24 Q. And Column 1, where did you get those numbers
25 from?
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1 A. Column 1 is as presented by the applicant in
2 their ARCR.
3 Q. And then Column 2 --
4 Well, tell us what the bottom line of
5 Column 1 is.
6 A. So the third missing item, accrued expenses,
7 again, you know, given that there's a payroll lag of
8 14 days, there is some positive impact to accrued
9 payroll at the end of the year, so that would have been
10 a benefit.
11 But the bottom line that the applicant has
12 proposed net of a $250,000 borrowing against their line
13 of credit, they would have seen a decrease in cash of
14 $347,000 at the end of the first year as they have
15 proposed. And, again, that is as the applicant has
16 proposed.
17 Q. Okay. And take us through Column No. 2, and
18 tell us where you got your figures from.
19 A. Basically, with Column No. 2, I started with
20 the Bureau's findings. They had proposed an operating
21 loss of $251,000 in their findings letter, which was
22 agreed to by the applicant. I had recalculated
23 accounts receivable, inventories, as well as accounts
24 payable and accrued expenses.
25 Q. And let me stop you right there. When you
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1 say you had to recalculate those, what do you mean?
2 A. Yes. The accounts receivable number based on
3 the higher bad debt ratio that the Bureau proposed, the
4 total net operating revenue minus bad debt was lower
5 than what the applicant proposed. So, thus, it would
6 have lowered the net accounts receivable on their books
7 at the end of 12 months.
8 So based on that, I recalculated the true
9 cash flow impact to the expected accounts receivable at
10 the end of the year.
11 Q. So let me just stop you, Mr. Bartus. The
12 accounting stuff I've got to go a little slow on.
13 So the columns that are, I'll call it, peach
14 in Column 2, your legend says "Calculated by AMR."
15 Where did you get the numbers that you used to
16 calculate these?
17 A. So from the accounts receivable perspective,
18 using the Bureau's proposed revenue and bad debt,
19 you're able to calculate accounts receivable on a
20 60 days outstanding, which the applicant also proposed
21 a 60 days outstanding. So using that average daily
22 revenue times 60 days, you can calculate that at the
23 end of the year they would have a $432,000 accounts
24 receivable balance.
25 Q. And where did you get the numbers used to
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1 calculate 40,000 in inventories?
2 A. The inventory, again, I just previously
3 discussed that it appeared to be missing from the
4 applicant's cash flow statement, because they had
5 indicated a $40,000 inventory balance.
6 Assuming that that is the same level of
7 inventory needed, and the Bureau did not change any
8 projections with respect to inventories or operating
9 expenses, I assumed that $40,000 would have -- should
10 have been the correct number reported as cash outflow
11 for inventory.
12 Q. And where did you get the accounts payable
13 number?
14 A. Accounts payable number and accrued expenses,
15 I had used the applicant's proposed operating expenses,
16 which the Bureau did not change in their findings, and
17 applied 45 days account receivable lag on general
18 operating expenses, as well as a 14-day lag on payroll
19 costs, to show that those lag times in paying that debt
20 actually produces a positive impact to the cash flow
21 statement for the applicant.
22 Q. And where did you obtain the 45-day lag and
23 the other you said, 14-day lag?
24 A. Those are the normal payment terms that AMR
25 operates under and is a consistent payment term that
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1 most organizations, whether they're Fire Districts or
2 Microsoft, operate under in the normal course of
3 business. So it is not unusual to see 45-day payment
4 terms, nor a 14-day payroll float.
5 Q. Okay. And using those normal time periods,
6 the applicant's information where accepted by the
7 Bureau, the Bureau's numbers, what's your bottom line
8 on the cash flow analysis using the Bureau's
9 calculations?
10 A. Using the Bureau's calculations, I prepared
11 the middle column highlighted in light blue.
12 Ultimately, I concluded that as a result of the
13 Bureau's projected loss, it would further erode cash to
14 the tune of $131,000 and leave them a balance of
15 approximately 327,000 at the end of the first year.
16 Q. So your blue column in the middle is not
17 meant to imply they will have a negative 131,000-plus
18 cash at the end of the year. That's just the
19 difference between Columns 1 and 2?
20 A. That's correct. The cash balance that would
21 be indicated by using the Bureau's findings would be
22 $327,523, which is on Row 23, Column 2.
23 Q. Okay. What's Column 3?
24 A. Column 3, as we discussed with my income
25 statement projection, as well as the balance sheet, is
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1 the resulting cash flow by using my pro forma
2 calculation of $578,919 loss.
3 Q. And that was the one that you prepared using
4 their expenses, but AMR's experience with regard to
5 revenue?
6 A. Correct. Yes. And since that revenue has
7 been relatively consistent over the years, that is more
8 than likely their revenue that is available to any CON
9 holder covering the same exact geography and performing
10 the same exact transports, that I believe was
11 2.9 million, was the rough figure, prior -- before bad
12 debt.
13 So applying CON 58's revenue against the
14 applicant's proposed expenses yielded a $578,000 loss.
15 And as a result of that loss, I recalculated the cash
16 flow statement. And, really, the only change at that
17 point was to reflect that the accounts receivable value
18 would be lower with lower revenue, and it would be a --
19 less of an impact to their cash flow.
20 Q. And using the existing provider's revenue
21 experience in the area and the applicant's pro forma
22 expenses, what's the impact to the cash flow statement?
23 A. So the impact to the cash flow statement on
24 Row 21 indicates that with the loss that the District
25 would incur in the first year, coupled with the working
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1 capital that would be used during the start-up,
2 including a $250,000 line of credit borrowing on
3 Line 20, that the District would still incur a $751,979
4 decrease in cash, as shown on Row 21, leaving a cash
5 balance of $53,728 after the first year of operation.
6 Q. And tell me what you have represented in the
7 very last column of AMR-27.
8 A. The last column is just, again, some formulas
9 that show the difference between what I believe to be
10 the correct pro forma for what the applicant has
11 proposed compared against what the applicant did
12 propose.
13 And the primary difference between the two is
14 the difference in net income. That would be the
15 primary driver of the cash impact for the District.
16 MS. FICKBOHM: Move for admission of
17 Exhibit LLA-27.
18 ALJ SHEDDEN: Is there any objection on
19 27?
20 MR. MEYERSON: No objection.
21 ALJ SHEDDEN: All right. 27 is
22 admitted.
23 All right. Why don't we take about
24 10 minutes and reconvene at, it looks like it will be,
25 2:54, 2:55.
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1 (A recess was taken from 2:44 p.m. to
2 2:56 p.m.)
3 ALJ SHEDDEN: All right. We're back on
4 the record, ready whenever you are, Ms. Fickbohm, to
5 have you pick up your questioning.
6 MS. FICKBOHM: Thank you.
7 BY MS. FICKBOHM:
8 Q. Mr. Bartus, in preparing LLA Exhibit 27, were
9 you mindful of the fact that the applicant proposes to
10 do 78 more transports than CON 58 reported on its 2015
11 ARCR?
12 A. Yes, I was mindful of that. And being that
13 it was not a material difference, I do not believe it
14 has a material impact on my analysis. I still firmly
15 believe that Hellsgate's model as they have proposed is
16 at risk for a half a million dollar loss.
17 Q. And tell us about the trend in obtaining
18 Medicare payments when you're a start-up operation.
19 A. Well, as I think we discussed at great length
20 yesterday, that there's an enrollment process that you
21 must go through to get an NPI number and to be able to
22 bill Medicare.
23 The first step in obtaining a provider number
24 is to go through an exhaustive enrollment application
25 with Medicare. You cannot begin that application
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1 process until you are a licensed provider, because one
2 of the conditions for the application is to provide
3 your authority to operate.
4 So as a new start-up, we couldn't even begin
5 to -- or any provider could not begin to pursue an NPI
6 number until they receive full authority to operate.
7 Q. So let me stop you just for a second there.
8 So if AMR Maricopa is already operational and
9 AMR is starting a second operation, can't it just use
10 the AMR Maricopa number?
11 A. Yes and no. The operation can use the same
12 NPI number, provided they are the same legal entity
13 providing the service. However, there is a process
14 with Medicare that you still have to submit an update
15 to your enrollment package, because you're now
16 operating in a different service area.
17 So you still need to go through a review
18 process with Medicare in terms of an expanded service
19 area to operate. So regardless of existing provider or
20 not, you still have to amend your Medicare enrollment
21 to account for changes in your business.
22 Q. And how long is that review process going to
23 take?
24 A. You know, it's a wide range, but over the
25 last year it seems to be that Medicare is really
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1 focusing real hard on the enrollment. They're very
2 particular about their information now. And we've seen
3 180-day waiting periods until we receive the complete
4 approval from Medicare with an NPI number.
5 Q. So that you've seen. What's the lowest range
6 that you've seen?
7 A. Anywhere from 120 to 150 days. I have not
8 heard of anything recent in our company experience
9 where we're receiving 30 or 60-day turnarounds for
10 Medicare. You know, we may turn around applications
11 quickly, but there are numerous times where we wait.
12 Q. And to get a Medicaid authorization, you have
13 to have your Medicare number first?
14 A. Yes, the first step is Medicare. And
15 Medicare will retroactively approve your NPI number so
16 that you have the opportunity to bill and collect. But
17 after that typical 180 days, you get your Medicare
18 number. You apply to Medicaid. That generally can
19 take 60, 90, 120 days as well. They will also backdate
20 the effective date so you can, you know, retro-bill for
21 claims.
22 At the same time that you're applying for
23 your Medicaid NPI number, you're also applying for any
24 agreements with third-party payors or now you're
25 getting enrolled with the third-party payor to show
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1 that you have a Medicare number now.
2 So even after getting your Medicare number,
3 there's not only Medicaid, but being an enrolled
4 provider for third-party insurance.
5 Q. And how does that impact a company that's
6 starting an ambulance transport business, that delay in
7 getting numbers?
8 A. Well, again, between all of the agencies
9 involved, if you're looking at 180 days for Medicare;
10 once you receive that from Medicare, your Medicaid
11 clock starts at zero, so now you're looking at another
12 60, 90, even 120 days for Medicaid, so your Medicaid
13 sales outstanding is reaching 200, 300 days; but, you
14 know, generally, you are starting your operations
15 incurring expenses from day one. Your employees are
16 getting paid in two weeks. You're still paying your
17 vendors. You can't make them wait six months. So you
18 are writing checks out the door to continue operation,
19 all the while not receiving any material cash inflow
20 from the result of your transports. So it's a
21 significant cash strain for any start-up.
22 Q. And how do you predict that would impact
23 Hellsgate if it received a CON?
24 A. I believe we did discuss this yesterday; but,
25 you know, in the event that Hellsgate is awarded a CON
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1 and they start up operations, it is reasonable to
2 expect that 180-day time period before you get your
3 Medicare and other associated provider numbers. You
4 have to be prepared to fund roughly half of your
5 operating expenses before you start receiving any
6 material cash deposits.
7 And I believe we walked through the math
8 yesterday, but, you know, Hellsgate would need to be
9 prepared to fund anywhere from 1.1 to $1.3 million of
10 operating expenses before they would receive any
11 material cash inflow to offset those expenses.
12 Q. And is that consistent with your experience
13 in the ambulance transport business from the financial
14 end?
15 A. Yes, it is, and it is consistent with the
16 experience we saw with AMR of Maricopa a little more
17 than a year ago with going through that process, where
18 we've incurred operating expenses during our enrollment
19 period and it took approximately 180 days and a little
20 bit longer for AHCCCS.
21 Q. Mr. Thomas, when he testified yesterday, told
22 us that he used the period of 2009 through 2012 to
23 predict bad debt for the Hellsgate operation. Do you
24 think that's reasonable?
25 A. I believe it was Mr. Taylor, right?
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1 Q. Mr. Taylor. Thank you.
2 A. No, I -- you know, 2009 through 2012 is a
3 roughly five to seven-year, you know, historical view.
4 I mean it's pretty far back in time. Medicare has
5 changed quite dramatically over the last five to seven
6 years, and we already know that AHCCCS changed their
7 reimbursement recently compared to 2009. I believe
8 AHCCCS in 2009 was paying 80 percent of your base rate
9 as an allowed number, and effective November 1st of
10 2015, they now pay 68.59.
11 So that would be a significant reduction in
12 expected revenues from AHCCCS, just, you know, 11 basis
13 points alone.
14 Q. Since -- subsequent to 2009-2012, have you
15 also noticed any trends with private payors?
16 A. Yeah. There's been -- you know, ObamaCare
17 has been the big topic over the last few years.
18 Another trend that we've seen over the last couple
19 years is a growth in high-deductible plans. Those
20 traditional plans of $500 deductibles and $10 office
21 visits are a thing of the past.
22 And flex accounts, healthcare spending
23 accounts, and high-deductible plans is, you know,
24 pretty much the world we live in now. And when you
25 provide services and the patient is still within their
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1 $2,000 or $4,000 high-deductible plan now, then you're
2 not billing the Blue Crosses of the world. You're
3 billing the patient. And when the patient gets a
4 $1,000, 1,500 or even $2,000 ambulance bill, those
5 become harder to collect than five, seven years ago.
6 So, you know, that impacts bad debt.
7 Q. What about Medicare sequestration that
8 Mr. Taylor said he didn't include in his calculations;
9 what's the impact if you don't consider that?
10 A. I believe -- I'm not sure of the exact year,
11 whether it was 2013, 2014; but as part of the Balanced
12 Budget Act, Medicare did implement a 2 percent
13 sequestration on the fee schedule. So although
14 Medicare publishes a fee schedule, they will only apply
15 98 percent of that fee schedule to your explanation of
16 benefits. And there's no opportunity to recoup that
17 from the member. You can only pursue 20 percent of the
18 allowable from the member, and the 2 percent is eaten
19 by the provider.
20 Q. So that would negatively impact Mr. Taylor's
21 computations also?
22 A. Yeah, I suspect it would be material,
23 considering Medicare is the primary payor in most
24 healthcare systems. It would be a material number to
25 lose 2 percent of your Medicare revenue.
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1 Q. Let's talk about financial benefits CON 58
2 has due to being part of the American Medical Response
3 organization.
4 What financial synergies are available to
5 CON 58?
6 A. Oh, there's numerous. For one, purchasing
7 power is probably the number one benefit to all of our
8 operations. Given the size, the scale, and, you know,
9 the broad geography that we cover in purchasing power,
10 I mean we're able to purchase ambulances at
11 significantly lower cost than a small company or even a
12 small Fire District would be able to obtain.
13 We're able to negotiate very cost-effective
14 supply costs with our vendor. Some of those costs are
15 better than some of the biggest hospitals in the U.S.
16 Fuel, as an example, is always a volatile
17 expense line item; but given our size and scope, we
18 have folks in our corporate finance department that are
19 always analyzing hedging opportunities, where we can
20 hedge fuel costs. If there's a speculation that fuel
21 prices will rise, which they typically do in the
22 summer, we have the opportunity to hedge and prepay
23 fuel at certain rates and offer those rebates through
24 our fuel vendor, fuel purchasing vendor, Wright
25 Express, to all of our operations throughout the U.S.
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1 And then, in addition, we, you know,
2 have great relationships with Physio-Control and
3 Medtronic. We're able to purchase all of our
4 equipment, whether they're stretchers or Life-Paks or
5 AEDs, at better rates than, you know, most other
6 organizations can.
7 Q. Tell me what you believe the financial impact
8 would be to CON 58 if Hellsgate's application is
9 granted?
10 A. Well, based on the number of transports they
11 have proposed and the service area that they have
12 included in their application, they are basically
13 looking to displace us. And it's going to be very hard
14 to financially justify sustaining operations when you
15 don't have a dollar of revenue coming in and we still
16 have to put expenses on the road. So when a business
17 is looking to displace us, that basically makes us, you
18 know, not viable for the go forward.
19 Q. We have an exhibit that's been admitted into
20 evidence showing a small number of calls, I think it's
21 23, in the -- transports in -- calls, calls in the very
22 northeast corner of Maricopa County that Hellsgate's
23 CON will not cover, because they only go as far as the
24 Maricopa County line, but that CON 58 is required to
25 cover.
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1 Is there any way that CON 58 could create a
2 financially viable plan to do those 23 or so calls a
3 year in that very rural area?
4 A. One call every 15 days, I don't believe
5 there's any financial plan that could be prepared to
6 sustain operations for 20-some-odd calls a year.
7 MS. FICKBOHM: I believe that's all my
8 questions, Mr. Bartus. Thank you.
9 ALJ SHEDDEN: All right. Mr. Ray, any
10 questions?
11
12 CROSS-EXAMINATION
13 BY MR. RAY:
14 Q. Just a couple related to Exhibit 27,
15 Mr. Bartus.
16 Whoop. Let's see.
17 MS. FICKBOHM: You can change the page
18 at the bottom if you want to change the page.
19 BY MR. RAY:
20 Q. All right. All right, old man eyes.
21 A. There is a zoom feature. There is a
22 plus-minus in that, if you wanted to do that.
23 MS. FICKBOHM: That's why I gave you
24 that paper.
25 MR. RAY: Yeah, thank you.
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1 BY MR. RAY:
2 Q. So if you take a look at, under your Revenue
3 column, if we focus on Less AHCCCS Settlements.
4 A. Yes, okay.
5 Q. Okay. Let's roll over to the third, your
6 ARCR. There is a significant difference between the
7 five-year average used by the Bureau in its
8 calculations of 722,000-and-change as a deduction from
9 revenue and Life Line's increase. Can you explain
10 what -- for 2015. -- what would justify that much of an
11 increase? A change in payor mix?
12 A. Yes, a change in payor mix is the primary
13 reason for that. You know, with the ObamaCare coming
14 into play a couple years ago, we did see, not only in
15 Arizona, in CON 58, but in many other parts of the
16 country, you know, we now have a population of people
17 that had no insurance are now Medicaid-eligible.
18 So we did see, over the course of the last
19 few years, that growth in Medicaid-eligible patients,
20 where in years past, pre-ObamaCare, they were private
21 pay, and we were receiving little to no funds for those
22 patients.
23 Q. Okay. Do you know what -- how much of a
24 percentage increase have you seen in your AHCCCS payor
25 mix? Do you know?
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1 A. Off the top of my head, I don't know.
2 Q. So you have a higher deduction from revenue,
3 but you have a lower bad debt, if you drop down in the
4 green column to the bad debt.
5 Can you -- let me see if I can pull it over
6 here so we can follow. Right here under -- the first
7 line under Expenses?
8 A. Correct, yeah.
9 Q. So rationalize that for me.
10 A. Well, we have less people in the private pay,
11 no insurance, that we're writing off as bad debt. So
12 now we have more people on AHCCCS. So, you know, you
13 would see less of an impact with your bad debt, now
14 that you have folks that are covered by AHCCCS. So
15 those deductions transfer up to AHCCCS settlements, as
16 well as other changes in payor mix in the market that
17 may be driving that.
18 Q. Let's -- I would like you to focus on
19 Column B now.
20 A. Sure.
21 Q. And it's titled Hellsgate Pro Forma with the
22 Applicant/BEMSTS Expenses. And as I go through -- so
23 as I go through this column, I'm having a hard time
24 figuring out when -- why you chose to use the Bureau's
25 calculations on one column and the applicant's in
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1 another. And let me just give you some examples here.
2 So we start with bad debt, which is down
3 here, and that number, what is that number? That's
4 different than your historical 2015 number, the
5 applicant's number, and the Bureau's number.
6 A. Yes. I wanted to give the benefit of the
7 doubt that with projected lower revenue, the applicant
8 would not incur as high as a bad debt as 760,000 that
9 the Bureau projected with 3,394,000 of net operating
10 revenue.
11 Q. Okay. So what you've done above that in the
12 revenue line is you've reduced the gross revenue by a
13 little over 200,000, and because of that you've reduced
14 their bad debt?
15 A. Correct. I recalculated --
16 Q. Okay.
17 A. -- with our experience of settlements, as
18 well as bad debt, as it would not have been appropriate
19 to carry forward the higher bad debt number since I had
20 adjusted gross revenue.
21 Q. Okay. All right. And then you're
22 utilizing -- you're not utilizing your payroll expense
23 line. You're utilizing the applicant's and the
24 Bureau's right below that, the million 720.
25 A. That's correct.
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1 Q. And why?
2 A. I don't know the applicant's payroll. They
3 know it better than I do. And as Mr. Maguire
4 testified, Fire Districts tend to have higher payroll
5 and benefit cost, particularly with the pension
6 liability. So given that that is what the applicant
7 believes it will incur in operating costs, I have no
8 reason to doubt that that's what they will incur.
9 Q. Okay. And the next two columns you've
10 utilized the applicant's numbers, or, I'm sorry, the
11 next two numbers in order, the 312,000 and the 106,000?
12 A. Correct. Again, I don't have any -- based on
13 my review, did not have any reason to expect anything
14 more than what the applicant and the Bureau have
15 proposed.
16 Q. Okay. And then we get to the Other Operating
17 Expense line, which is represented by a $745,000
18 figure. And that is not the applicant's number. That
19 is the Bureau's number?
20 A. That's correct. I believe in this case the
21 Bureau did calculate a slightly lower vehicle cost, and
22 I felt that that was reasonable to bring forward.
23 Q. All right. Thank you, Mr. Bartus.
24 MR. RAY: I don't have any other
25 questions.
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1 THE WITNESS: You're welcome.
2 ALJ SHEDDEN: All right. Mr. Meyerson.
3 MR. MEYERSON: Yes.
4
5 CROSS-EXAMINATION
6 BY MR. MEYERSON:
7 Q. I'm sorry. Looking at your resumé, I just
8 wanted to clear one thing up. It says "Regional CFO"
9 or something. What region is that?
10 A. It is the South Region of AMR. AMR is
11 broken up into three regions, just because of our size
12 and scope. We have an East Region that generally
13 covers the eastern half of the United States, South
14 Region that covers the whole southern half, maybe from
15 Mississippi through Arizona and Nevada; and then a West
16 Region that sort of covers the West/Northwest of AMR.
17 Q. Okay. Thank you for clarifying that.
18 A. You're welcome.
19 Q. I want to clarify one thing before we
20 continue on these tables. These tables are based on
21 2015 ARCR, correct, as far as the Life Line/AMR number
22 or --
23 A. Yes.
24 Q. -- Life Line number?
25 A. Yes, the 2015 ARCR number from Life Line, as
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1 well as what the applicant --
2 Q. Was AMR in charge of operations of CON 58 in
3 2015?
4 A. We were -- I believe we were operating under
5 temporary authority as owners sometime in October, but
6 for the large part of 2015 we were not.
7 Q. So when you say "we" and "AMR" and refer to
8 the 2015 numbers, it's a little bit misleading, right,
9 because almost three-fourths of the year you weren't
10 operating the CON at all?
11 A. Define "you." Me personally, I wasn't, or --
12 Q. Well, AMR.
13 A. Okay, AMR. That's why I was looking for
14 clarification.
15 No, AMR, for a large majority of 2015, was
16 not the owners of CON 58.
17 Q. So you don't really know if the Medicare
18 settlements, AHCCCS settlements, bad debt, you don't
19 really know if those were minimized, and you don't know
20 if revenue was maximized based on the 2015 numbers,
21 correct?
22 A. I can't speak to their billing and collection
23 process prior to that.
24 Q. But your financial analysis assumes all of
25 this is correct and that everything is maximized for
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1 purposes of applying it to the Hellsgate numbers?
2 A. The CON was prepared in accordance with
3 generally accepted accounting principles, and they were
4 approved by our auditors in terms of the entire
5 financials. So I have to assume at that point that the
6 auditors did do due diligence and signed off on the
7 financials.
8 MS. FICKBOHM: And just I'm going to
9 make a record of clarification. I think you just said
10 the CON. And Jody is nodding. So did you mean the
11 ARCR?
12 THE WITNESS: Yes. Sorry.
13 BY MR. MEYERSON:
14 Q. No problem.
15 But I'm not questioning whether they're
16 correct. I'm questioning whether or not the results of
17 operation reflect the best numbers that should be used
18 here, because you, being AMR, weren't in charge of the
19 operations for three-fourths of the year.
20 A. So what's your question?
21 Q. I guess with Rural/Metro in control, in the
22 middle of a bankruptcy, trying to transition a CON, and
23 no additional input into the operations, can these
24 numbers be relied on as the right numbers to use for
25 this analysis?
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1 A. I find them very reliable if the external
2 auditing firm signed off on them that they were in
3 accordance with generally accepted accounting
4 principles.
5 Q. Well, again, I agree that the numbers are
6 correct. I'm not saying they're not correct. But an
7 auditor doesn't come in and say, "Did you maximize
8 revenue and minimize expenses?" They come in and say,
9 "Yes, your revenue was X. We agree. Your expenses
10 were Y. We agree. Everything's good to go."
11 It doesn't have anything to do with
12 efficiency or collections or anything like that,
13 correct?
14 A. I can't attest to whether they were efficient
15 or inefficient at all.
16 Q. You also mentioned synergies. You talked
17 about AMR synergies and buying power.
18 Does any of that impact Hellsgate's ARCR as a
19 result of operations if it were awarded a CON?
20 A. Our purchasing power would not apply to
21 Hellsgate.
22 Q. Okay. And I did want to walk through this,
23 and pardon me. It's like the lighter green column on
24 the first page, the green column farther to the right
25 than the other ones.
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1 A. Sure.
2 Q. Other than lowering the bad debt by 80-some
3 thousand dollars, I mean using the numbers here really
4 is a worst-case scenario for Hellsgate. You're using
5 the rates that produce the least amount of revenue, and
6 then you're increasing their settlements for both
7 AHCCCS and Medicare. And the only other number,
8 really, that you're adjusting is bad debt, and you're
9 giving them a little bit of credit for that.
10 So other than that bad debt number, this
11 column is like worst-case scenario for Hellsgate; would
12 you agree with that?
13 A. Worst-case scenario, I would not agree. It
14 is my opinion that this is what to expect based on our
15 operating experience and the expenses proposed that it
16 will cost Hellsgate to run the same service area. I --
17 Q. In 2015, when you operated the CON for three
18 of the 12 months, correct?
19 A. What's -- I'm basing it off of our revenue
20 experience and the costs proposed by Hellsgate. So I
21 don't deem that to be a worst-case scenario. I believe
22 that to be my opinion as to the realistic expectation.
23 Q. But only three months of the 2015 ARCR that
24 you're using to impose on Hellsgate was actually months
25 in which AMR was in charge of the operations?
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1 A. That's correct. I have no reason to doubt
2 those numbers, though.
3 Q. You've heard testimony surrounding the
4 368 interfacility transports, correct?
5 A. Yes.
6 Q. And as one of the lead financial officers or
7 regional officers over the South, with assuming CON 58
8 under your purview, would you agree that the
9 performance of CON 58 is important to you?
10 A. I would agree.
11 Q. That maximizing profit, maximizing revenue is
12 an important part of that process?
13 A. I would agree.
14 Q. And I hate to do this, because I need you to
15 do some math for me, because I was thinking about this
16 368 trend. So do you happen to have a phone that we
17 can do some simple math on?
18 A. I do not have a phone.
19 Wait, I do. I didn't think I did. I do. I
20 thought I left it over there, because this big thing
21 slows me down.
22 Q. Do you know how many interfacility transports
23 were done -- we only have data on interfacility
24 transports from January 1st through the end of August.
25 Do you know offhand how many have been done since
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1 then --
2 A. I don't.
3 Q. -- September, October, November, prior to
4 December?
5 A. I do not know.
6 Q. Okay. For our purposes, I would like to just
7 use an annualized number, if that's okay with you. And
8 to get that, would you agree with me that if you took
9 the 368 through eight months, so if you take 368 and
10 divide by 8, that will give you your per month number;
11 and then multiply it by 12 to get the annualized
12 number?
13 A. Sure.
14 Q. And did you do that on there?
15 A. Yes.
16 Q. And what did it come to?
17 A. 552.
18 Q. And do you happen to know the Maricopa County
19 unified rate for the Southwest Ambulance and PMT?
20 A. Not the exact number, without looking at the
21 charge schedule from DHS; but it's probably somewhere
22 just south of $900.
23 Q. Yeah, that's -- that's all right. That's
24 really good.
25 A. 898 and change, if I --
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1 Q. Yeah, that's pretty good, yeah, 898 --
2 A. 56 cents?
3 Q. -- 56.
4 A. Thank you.
5 Q. Yeah, very nicely done.
6 A. Give or take.
7 ALJ SHEDDEN: I'm going to caution you,
8 you're talking at the same time.
9 MR. MEYERSON: I was impressed. I'm
10 sorry.
11 BY MR. MEYERSON:
12 Q. So can you multiply the 898.56 by the 552,
13 and tell us what that comes out to?
14 A. 496,005 gross dollars.
15 Q. And then if I told you the mileage rate for
16 the Maricopa County ambulances were $18.63, would that
17 sound about right?
18 A. That number I do not know, but I will trust
19 that you are representing that as the correct number.
20 Q. Okay. Well, assuming for our purposes that
21 your CON 58 ambulances aren't driving a hundred miles
22 to do a ten-mile interfacility transport across Payson,
23 let's assume a hundred miles for each of these
24 transports as an average.
25 Can you multiply 552 times 100 times $18.63?
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1 A. 1,028,376.
2 Q. Yeah. And, I'm sorry, I think I misspoke the
3 mileage rate for CON 58.
4 And then if you would add the previous number
5 to that, the 496,005?
6 A. Okay. Can I ask for a clarification? You
7 just stated that you misstated the mileage number
8 for --
9 Q. No, no, no. Just the -- I think the CON
10 number.
11 A. Oh, okay. Yeah.
12 I got rid of those two numbers, so it's
13 probably a million 520 and change.
14 Q. Rather than have you do the math, the
15 difference between that, having a Maricopa County
16 ambulance provide those interfacility transports and
17 having a CON 58 ambulance do those transports, is
18 approximately $535,000, because of the lower rate for
19 the Maricopa County ambulances.
20 Are interfacility transports generally more
21 profitable than 911/emergency calls?
22 A. Just for clarification, you said the
23 difference would be 500-and-what-thousand?
24 Q. 36,000, $535,000?
25 A. In gross charges, correct?
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1 Q. In gross charges, yes.
2 A. Okay. I'm sorry. What was your --
3 Q. Yeah. My question was, would you agree that,
4 generally speaking, interfacility transports are more
5 profitable than 911/emergency calls?
6 A. Well, generally speaking, I think that
7 depends on the market. I don't think you can make that
8 characterization. I think as Mr. Jones even testified,
9 you see one ambulance operation, you see one ambulance
10 operation. But I don't know if that's a
11 characterization that can be applied nationally.
12 Some systems from the 911 side do receive
13 government subsidies to fund the operations, so in some
14 of those instances there's no difference in
15 profitability between 911 and interfacility; but I
16 guess it would depend on the specific area.
17 Q. Would it be more profitable for interfacility
18 transports versus 911/emergency calls for the payor mix
19 in CON 58?
20 A. Can you repeat that question, maybe, if Jody
21 wants to read it or --
22 MR. MEYERSON: Yeah, she can read it.
23 (The record was read by the court
24 reporter as follows:
25 QUESTION: Would it be more profitable
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1 for interfacility transports versus
2 911/emergency calls for the payor mix in
3 CON 58?)
4 THE WITNESS: I'm not sure I can answer
5 that without, you know, kind of doing a detailed
6 analysis of that. Again, every ambulance operation is
7 different.
8 BY MR. MEYERSON:
9 Q. Would you agree that if Life Line leaves the
10 area, that the AMR entities from Maricopa County will
11 most likely stop providing interfacility transports
12 from CON 58 to Maricopa County?
13 A. I would have to defer that to our operations
14 group. I mean I would -- we would review the data and
15 do a financial assessment, but ultimately, if Life Line
16 has an abil -- not ability; a requirement to fulfill
17 those CON obligations, then the operations would make
18 the necessary adjustments to adhere to their CON
19 requirements.
20 But whether they would do them, I would have
21 to defer to operations in terms of, you know, they
22 would develop a more detailed SSM and operations plan
23 to determine if that's even something they could do.
24 Q. The amount of revenue that would be generated
25 in CON 58 if CON 58 provided 552 interfacility
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1 transports is, with the mileage reimbursement, is over
2 $2 million.
3 MS. FICKBOHM: And I -- Your Honor, I'm
4 sorry to jump in here. I didn't object before because
5 I thought we were done with it, but now we're going to
6 spend more time.
7 I don't understand the relevancy of this
8 part of the discussion, because when you're comparing
9 the operations side by side, the applicant didn't apply
10 to do 3,552 transports as part of its operations.
11 There's only a 78-transport difference between CON 58's
12 2015 ARCR transport numbers and what the applicant
13 proposes its operation is going to look like and what
14 it supposedly is going to staff in order to cover.
15 So counsel is now saying, oh, there
16 should be 552 additional transports added into the
17 money. And I don't think that that's a reasonable
18 discussion, because CON 58 didn't do it in 2015, and
19 Hellsgate isn't saying that they're going to do it if
20 they get a CON.
21 So this whole discussion seems
22 irrelevant to me and wasting time.
23 ALJ SHEDDEN: All right. Mr. Meyerson,
24 do you want to respond on the relevance objection?
25 MR. MEYERSON: Yeah. I mean it goes
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1 directly to all of the various numbers that are being
2 altered and given to us on Mr. Bartus' spreadsheet here
3 and changing numbers and showing different
4 possibilities of operations. And I'm just merely
5 suggesting, one, that, first off, there may be
6 additional, but at the very least, it accounts for the
7 additional transports that we've included in the ARCR
8 that they have questioned since the beginning of this
9 hearing.
10 ALJ SHEDDEN: Well, I'm going to
11 overrule the objection; but, you know, I don't -- if he
12 took the figures from your pro forma ARCR, it's a
13 little hard for me to see how you can contend that
14 those are wrong. But I'll overrule the objection, and
15 you can go ahead and ask your questions.
16 BY MR. MEYERSON:
17 Q. So I started to say that the interfacility
18 transports, the 552 annualized, represent about
19 $2 million in additional gross revenue. Would you
20 agree that adding that revenue would significantly
21 change your financial analysis as set forth in your
22 exhibit?
23 A. Well, by nature of adding 552 more transports
24 to any operation, including CON 58, yes, it would
25 increase revenue.
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1 Q. You also heard testimony from Chief Bathke.
2 I think you were here for the Chief's testimony? Yes?
3 A. Yes.
4 Q. About a personnel model that he said could be
5 employed by the applicant at the 3,000-transport model.
6 Would you agree that that would decrease
7 personnel costs? If you want me to remind you of what
8 he said, and then I can restate the question.
9 A. Yeah.
10 Q. It was the model where there was a single EMT
11 on an ambulance and then the engine would respond, and
12 if a transport was necessary, the medic from the engine
13 could ride in with the EMT to staff the ambulance.
14 Would that decrease personnel costs?
15 A. Yes, it would decrease costs. But that is
16 not what the applicant had proposed, and I had no
17 ability to analyze that.
18 Q. You also heard the Chief testify about a
19 capital lease arrangement where there would be a
20 12-month abatement of the lease payment.
21 Would that provide additional cash flow that
22 would be available to Hellsgate in the first year?
23 A. I believe their ARCR did represent capital --
24 I'm sorry, operating lease payments of -- it was
25 roughly 39,500 times 5. I believe that's what they
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1 represented in the ARCR.
2 So your question is on a capital lease?
3 Q. Yeah, cash flow, with a rent abatement of
4 12 months, would that impact?
5 A. Yeah, if they had proposed a capital lease,
6 then it would have changed all of the ARCR documents,
7 from the balance sheet to the cash flow to the income
8 statement.
9 Q. As well as the analysis that you did here?
10 A. Yes. My analysis is dependent upon the
11 applicant's application.
12 Q. Okay. Thank you, Mr. Bartus. Appreciate it.
13 ALJ SHEDDEN: Ms. Fickbohm, any
14 follow-up questions?
15 MS. FICKBOHM: Briefly.
16
17 REDIRECT EXAMINATION
18 BY MS. FICKBOHM:
19 Q. Mr. Bartus, is it important, for purposes of
20 your calculations, who was running the ambulance
21 transport operation during calendar year 2015?
22 A. In terms of whether it was Rural/Metro versus
23 AMR? No, not really. I mean these were -- these
24 financials were certified by a third-party auditor, so
25 I have no reason to doubt that those are the operating
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1 results as reported under generally accepted accounting
2 principles.
3 Q. And I think what counsel was trying to
4 suggest to you was that you can't say that when AMR
5 wasn't there, that appropriate billing and collection
6 efforts were made. I think that's what he's trying to
7 suggest.
8 So let me just ask.
9 MS. FICKBOHM: I hate to leave this
10 document if it's going to be hard to get back to it,
11 Judge, but I wanted to go to another exhibit.
12 BY MS. FICKBOHM:
13 Q. Or maybe you know this. Maybe we don't have
14 to.
15 Do you know what the net income shown on the
16 ARCR for 2015 for CON 58 was?
17 A. You can pull it up.
18 Q. Okay.
19 A. I believe it was roughly 203,000.
20 Q. Okay. Let me go to that so I'm not making
21 you guess. This isn't a memorization.
22 A. And I'm not going for the last three numbers,
23 although I'll take a guess and say 497.
24 Q. Let's see. I'm going to HG-24a, to Page 2 of
25 the -- No. 2 of the document and Page 4 of the PDF.
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1 Does this refresh your recollection as to
2 what the net income figure was?
3 A. Yes. $244,793 after tax.
4 Q. Given your Arizona experience, the size of
5 this entity, the geography, et cetera, and the number
6 of transports done, does that figure speak of a lack of
7 good attention to collection and billing practices?
8 A. No. If there was a lack of attention to
9 billing and collections, that number would be in the
10 red, negative.
11 MS. FICKBOHM: I don't have any other
12 questions, Mr. Bartus.
13 ALJ SHEDDEN: Mr. Ray, nothing?
14 MR. RAY: Nothing.
15 ALJ SHEDDEN: Anything else,
16 Mr. Meyerson?
17 MR. MEYERSON: No, thank you.
18 ALJ SHEDDEN: All right. Thank you,
19 sir.
20 THE WITNESS: Thank you.
21 ALJ SHEDDEN: All right. Who's the next
22 witness?
23 MS. FICKBOHM: Jim Roeder.
24 ALJ SHEDDEN: All right. Come on up.
25 All right. Let me get you sworn in, if
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1 you would raise your right hand.
2
3 JIM ROEDER,
4 called as a witness on behalf of the Intervenor herein,
5 having been first duly sworn by the Administrative Law
6 Judge to speak the truth and nothing but the truth, was
7 examined and testified as follows:
8
9 ALJ SHEDDEN: All right. Please state
10 and spell your name for our record.
11 THE WITNESS: Jim, J-I-M, Roeder,
12 R-O-E-D-E-R.
13 ALJ SHEDDEN: All right. Whenever
14 you're ready, Ms. Fickbohm.
15
16 DIRECT EXAMINATION
17 BY MS. FICKBOHM:
18 Q. Good afternoon, Mr. Roeder.
19 A. Hi.
20 Q. I have up on the screen what's been marked
21 for purposes of identification as LLA-13g. Can you
22 tell us what this is?
23 A. Pardon?
24 Q. Do you recognize this document?
25 A. Yes.
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1 Q. And what is that?
2 And what is it?
3 A. It's my bio.
4 Q. Okay. I'm not going to have you read it to
5 us, but could you provide the Judge and the Director a
6 summary of your career in the emergency medical
7 services field?
8 A. Sure. I became a basic EMT in 1976 in a town
9 of 800 in Missouri. From there I went to nursing
10 school, managed the Emergency Department in a local
11 hospital. Moved from there to a new hospital in
12 another town; managed the Emergency Department there
13 and developed an ambulance service out of that
14 Emergency Department.
15 Then I moved to the Level I Trauma Center at
16 University of Missouri in Columbia. I worked there in
17 a thoracic intensive care unit for eight very long
18 months, and moved from that to working on their
19 helicopter service as a flight nurse. I did that for
20 two and a half years.
21 Moved to Tucson, where I was the chief flight
22 nurse of UMC AirCare for five years. From there I
23 moved to Southwest Ambulance in 1994; developed and
24 managed their training and education department. As
25 time went along, became responsible for managing the
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1 scheduling department, OSHA compliance, other
2 government compliance.
3 Rural/Metro bought the company. I became
4 national director of OSHA compliance for Rural/Metro
5 Corporation. In 2001 I left Rural/Metro to go to work
6 for Bob Ramsey's companies, and for a little over a
7 year traveled to Las Vegas every week to work at Medic
8 West.
9 And subsequently from there, managed American
10 ComTrans here in the valley and then American
11 Ambulance. LifeStar then purchased -- I'm sorry, not
12 LifeStar. Bob's company purchased PMT. StarWest
13 purchased PMT, and I was clinical director for that
14 company and also did compliance for them.
15 We were subsequently bought by Rural/Metro,
16 where I did regulatory compliance for them.
17 AMR purchased the company, and I'm currently
18 the regulatory manager there.
19 MS. FICKBOHM: Your Honor, I would move
20 for admission of Exhibit 13g.
21 MR. MEYERSON: No objection.
22 ALJ SHEDDEN: All right. 13g is
23 admitted.
24 BY MS. FICKBOHM:
25 Q. And, Jim, you additionally have some
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1 professional activity that relates to regulatory
2 compliance, correct?
3 A. That's correct.
4 Q. As stated on your resumé.
5 In Arizona, is a big part of regulatory
6 compliance reporting to the Department of Health
7 Services with regard to ambulance response times,
8 numbers of transports, et cetera?
9 A. Correct.
10 Q. And does that continue to be part of your
11 obligations for the American Medical Response family?
12 A. It does.
13 Q. I would like to show you what has been marked
14 as 14. Is this a document that you created?
15 A. It is.
16 Q. And can you tell us how you went about
17 creating it?
18 A. Sure.
19 I get a report every month showing the number
20 of emergency calls and the response time for each of
21 those, and developed that report into the response time
22 tolerances that are on CON 58's CON and record that.
23 Under Statute the State tracks your
24 compliance tolerance on a 12-month basis, so I keep it
25 in a rolling 12-month basis, and this is the rolling
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1 12 months at the end of August of 2016. Below that is
2 the same calculations for the calls that are just in
3 the city of Payson.
4 Q. And so tell us what this document
5 demonstrates.
6 A. It tells us that CON 58 is in compliance with
7 the required response time tolerances of the State and
8 our CON.
9 Q. And you drilled down to just the city of
10 Payson itself. The top one is the entire service area?
11 A. The top one is the entire service area, the
12 bottom one the city of Payson itself.
13 Q. And when the Department of Health Service
14 looks at CON response fractile compliance, does it
15 focus on individual areas or look at the CON area as a
16 whole?
17 A. It only looks at the whole CON.
18 Q. So this gives us a better look at response
19 time compliance within the city limits of Payson?
20 A. That's correct.
21 MS. FICKBOHM: I would move for
22 admission of LLA-14.
23 ALJ SHEDDEN: Is there any objection on
24 14?
25 MR. MEYERSON: No objection.
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1 ALJ SHEDDEN: All right. 14 is
2 admitted.
3 BY MS. FICKBOHM:
4 Q. I'm going to show you HG-20g.
5 I'm tracking over here whether or not these
6 have been admitted, so I'm not sure if that one, 20 --
7 which has already been admitted into evidence.
8 And looking at Page 1 of it, that's your
9 signature?
10 A. It is.
11 Q. And it attaches a response time compliance
12 letter from you to the Department at the very end, that
13 we will get to momentarily. Probably a quicker way to
14 do this.
15 We're on Page 16 of the -- the last page of
16 the PDF. It's a second letter also from you, correct?
17 A. That's correct.
18 Q. There was some suggestion during the
19 applicant's case-in-chief that these calculations may
20 have been intended by you or understood by DHS to
21 include interfacility transport calls.
22 Does this include interfacility transport
23 calls?
24 A. It does not.
25 Q. And do you believe any person would
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1 reasonably understand it that way?
2 A. Yes. It's commonly known that response time
3 tolerances reported to DHS do not include interfacility
4 calls.
5 Q. Unless you have an interfacility transport
6 requirement?
7 A. Correct.
8 Q. Now we're going to go to a document that's
9 already been admitted as LLA-22, a map of the
10 applicant's proposed service area and the Hellsgate
11 Fire District boundaries.
12 Are you the person who prepared this?
13 A. I am.
14 Q. And can you tell us how it is you went about
15 preparing this document?
16 A. The proposed service area for the Hellsgate
17 CON was prepared from their amended service area from
18 their application, and the Hellsgate Fire District area
19 in the middle of that --
20 Q. Represented by the dark blue?
21 A. Correct.
22 -- was prepared using the maps on the
23 Hellsgate Fire District website.
24 Q. So you heard some suggestion from the Chief
25 that that's not an accurate depiction; but according to
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1 their website, is it an accurate description?
2 A. It's exactly what's represented on their
3 website.
4 Q. And did you try to roughly guesstimate the
5 difference in size between their proposed service area
6 as compared to the Fire District area itself?
7 A. It's approximately 40 times greater than the
8 Fire District.
9 Q. I'm going to LLA-17, which I believe has
10 already been admitted with a foundation objection.
11 Yes, 17a and 17b have already been admitted.
12 Can you tell me if this is a document that
13 you prepared, Jim?
14 A. It is.
15 Q. And tell us, first, how it is you went about
16 preparing this document.
17 A. I took the map of the proposed service area
18 overlaid over the CON 58 service area. I then took the
19 CAD report of all the emergency transports where a unit
20 arrived -- I'm sorry, not transports; calls where a
21 unit arrived on scene for the 12 months ending August
22 the 31st of this year, and I populated those into those
23 maps. Then --
24 Q. You have software that will allow you to do
25 that?
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1 A. I do. It's made by DeLorme, which is the
2 largest CD map producer in the United States.
3 Our CAD tracks latitude and longitude for
4 each call, and I used that to locate the calls into the
5 map. I then counted the number of calls between the
6 Hellsgate proposed CON service area and the southwest
7 edge of CON 58 service area, which is the area in
8 Maricopa County that Hellsgate originally requested and
9 subsequently withdrew from.
10 I also was able to click on each of those
11 calls on the map and obtain the run number associated
12 with that call and the location. And that's what is
13 shown on this particular exhibit.
14 Q. And did that same data look allow you to
15 determine what the issue was reported by dispatch
16 requiring an ambulance transport response?
17 A. By taking the run number and going back to
18 the CAD report, it would tell me -- it told me what the
19 problem was that we were responding to.
20 Q. And so you personally prepared this?
21 A. I did.
22 Q. And so I just want to clarify. This is the
23 very southwest corner of CON 58, the little tiny part
24 that's included -- or the small part that's included in
25 Maricopa County, but has been excluded by the
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1 applicant?
2 A. That's correct.
3 Q. And did you check your research results? Did
4 you check each one of these to make sure it was true
5 and accurate?
6 A. I did. And, furthermore, I had Edward Armijo
7 verify them.
8 Q. So you double-checked. Thank you.
9 MS. FICKBOHM: Your Honor, I would move
10 for -- oh, we already have this admitted? It's -- you
11 just -- there was a foundation objection.
12 BY MS. FICKBOHM:
13 Q. Okay. We will go next to 17b. And did you
14 also prepare this, Jim?
15 A. I did.
16 Q. And tell us how you did that and what this
17 shows.
18 A. This chart comes from the same exercise that
19 I just performed for the previous one. In fact, I
20 populated all of them at the same time and just created
21 two separate reports from the same effort. And these
22 calls were the ones that I found east of CON 58.
23 Q. Outside of the service area?
24 A. It's outside of CON 58, outside of the
25 proposed Hellsgate CON, and, in fact, is in an area
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1 that is not included in any CON.
2 Q. And you were looking at the same period of
3 time?
4 A. Yes.
5 Q. And did you double-check the accuracy of this
6 determination?
7 A. These I also double-checked and also had
8 Edward Armijo double-check them.
9 Q. Specifically going back to 17a, the
10 Maricopa -- the calls from that section of Maricopa
11 County excluded by the applicant, you heard Chief
12 Bathke testify that there have not been any calls
13 generated from that area for a long time?
14 A. I did hear that.
15 Q. And based upon your research, is that an
16 accurate statement?
17 A. It is not.
18 Q. And what is Highway 87?
19 A. Highway 87 is the highway that runs from
20 Maricopa County up through Payson and on north.
21 Q. Thank you, Mr. Roeder.
22 MS. FICKBOHM: No further questions.
23 ALJ SHEDDEN: All right. Mr. Ray, any
24 questions?
25 MR. RAY: No questions.
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1 ALJ SHEDDEN: And, Mr. Meyerson.
2 MR. MEYERSON: I have just a few.
3
4 CROSS-EXAMINATION
5 BY MR. MEYERSON:
6 Q. Do you, being AMR, keep track of waiting
7 times on interfacility transports? Not for reporting
8 purposes, but just keep track of them generally?
9 A. Do I personally?
10 Q. No, AMR.
11 A. AMR? They track them for CON 136.
12 Q. They do not track interfacility transports
13 waiting -- response times for CON 58?
14 A. Not at this time.
15 Q. And 17a, really quick, I think it's up right
16 now.
17 No?
18 Yes.
19 MS. FICKBOHM: Yes.
20 BY MR. MEYERSON:
21 Q. Yes, 17a is up.
22 Is there, to your knowledge, another CON
23 holder that is in that area?
24 A. Yes.
25 Q. Which CON holder is that?
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1 A. CON 136 covers that.
2 Q. And then in 17b, these were the calls here --
3 it's your understanding that these calls are outside of
4 CON 58?
5 A. That's correct.
6 Q. And as Ms. Fickbohm mentioned, you were here
7 when Chief Bathke said that if called, Hellsgate, if
8 awarded a CON, would respond to both areas depicted in
9 17a and 17b, correct?
10 A. Correct.
11 MR. MEYERSON: That's all I have, Your
12 Honor. Thank you.
13 ALJ SHEDDEN: Any follow-up questions?
14 MS. FICKBOHM: Nope.
15 ALJ SHEDDEN: All right. Thank you,
16 sir.
17 Why don't we take about 10 minutes
18 until -- we'll call it nine minutes, till 5 after 4:00.
19 Who is going to be the next witness?
20 MS. FICKBOHM: Mr. Valentine.
21 ALJ SHEDDEN: All right. Thank you.
22 (A recess was taken.)
23 ALJ SHEDDEN: All right. We're back.
24 Mr. Valentine is in the witness chair, so we're going
25 to get you sworn in.
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1 JOHN VALENTINE,
2 called as a witness on behalf of the Intervenor herein,
3 having been first duly sworn by the Administrative Law
4 Judge to speak the truth and nothing but the truth, was
5 examined and testified as follows:
6
7 ALJ SHEDDEN: All right. Go ahead and
8 state and spell your name for our record, please.
9 THE WITNESS: My name is John, J-O-H-N,
10 Valentine, V-A-L-E-N-T-I-N-E.
11 ALJ SHEDDEN: All right. Whenever
12 you're ready, go ahead.
13
14 DIRECT EXAMINATION
15 BY MS. FICKBOHM:
16 Q. Good afternoon, Mr. Valentine.
17 A. Good afternoon.
18 Q. Please tell us how you're currently employed.
19 A. I am currently the regional director of
20 the -- part of the Arizona market with American Medical
21 Response.
22 Q. And what part of the Arizona -- part of the
23 state of Arizona do you cover?
24 A. So I currently cover the River Medical
25 operation, which is located along the Colorado River,
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1 which includes from Quartzsite, Arizona all the way to
2 Kingman, Arizona and a lot of dirt in between there. I
3 oversee the Prescott Life Line operation, which is
4 about 9,000 square miles as well. I oversee the Payson
5 operation. I oversee four --
6 Q. And that would be CON 58?
7 A. CON 58, yes, ma'am. Sorry.
8 Q. Okay.
9 A. I oversee four large 911 systems here in the
10 valley; Scottsdale, Chandler, Tempe and Peoria. I work
11 alongside with our other regional director here, John
12 Karolzak. I also cover Safford, Arizona and Tri-City.
13 A lot of these are legacy PMT operations that are now
14 rebranded or will be rebranded into the Life Line name.
15 Q. So tell us how it is that you came to become
16 involved in the emergency medical services profession.
17 A. Well, way back when there used to be a
18 television show called Emergency. Some of the folks
19 are old enough to remember that show. It was a very
20 appealing show when I was a young child. I always
21 wanted to be a firefighter/paramedic from that point
22 on.
23 Right out of high school I went to school to
24 become an emergency medical technician. I was torn
25 between police officer and emergency medical
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1 technician, going on to be a firefighter. I got into
2 the EMS world at a very young age and have been with it
3 ever since.
4 I spent a little time in California from
5 about 1980 to about 1983. I went through paramedic
6 program at the Daniel Freeman Institute in Inglewood,
7 California. At that time paramedic programs were
8 basically county to county. I had an opportunity to
9 come to Arizona. I came to Arizona, challenged the
10 program here, and went to work as an emergency medical
11 technician here in Arizona.
12 From there I worked for a private ambulance
13 service, River Medical, Incorporated, for about four
14 years. And from that point I moved on and went to work
15 for a small Fire District called Quartzsite Fire
16 Department. I worked there from 1984 until about
17 ninety -- I'm sorry, from 1988, excuse me, until later
18 on, about 1999. I left there as a division chief. My
19 responsibilities were coordinating EMS and overseeing
20 the EMS division. I worked as an operations chief and
21 ran the day-to-day operations of the Fire Department.
22 I left there and went to the Colorado River
23 just up from Quartzsite. I was looking for a
24 Department where I could spent a little bit more time
25 with my family, and I was looking for more shift work.
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1 As a Chief, you're pretty much on call 365 days a year,
2 7 days a week.
3 I lateraled, basically, over there as a
4 Captain. Spent a couple years there and had an
5 opportunity to go back to private sector shortly
6 thereafter and ended up going back to River Medical.
7 And River Medical was acquired by AMR in 2008. I
8 spent -- and I've been there ever since.
9 Q. And you were the operations manager at River
10 Medical?
11 A. I was the operations manager. I oversaw
12 day-to-day operations of the southern quadrant of our
13 9,000 square miles of operation area, very rural
14 section of our -- La Paz County.
15 Q. And subsequent to AMR's purchase of River
16 Medical, did your position there change?
17 A. It did. I was the general manager over River
18 Medical. There was a change in leadership in New
19 Mexico. I was asked to go run several operations in
20 New Mexico, two high-speed 911 systems; one in
21 Las Cruces, New Mexico and a much more rural, smaller
22 operation in Alamogordo, New Mexico, both run by AMR.
23 And then I was instrumental in working a new market in
24 Albuquerque, New Mexico, which was both an IFT and a
25 911 operation in Valencia California; or, I'm sorry,
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1 Valencia, New Mexico.
2 Q. So would it be fair to say that until very
3 recent times, when American Medical Response developed
4 a presence in the Greater Phoenix/Maricopa County area,
5 most of your experience has been in the rural
6 environment?
7 A. That would be accurate, yes.
8 Q. And as the regional director -- well, first
9 of all, let me clarify.
10 You're currently a paramedic, correct?
11 A. I still am, yes, a State-certified paramedic.
12 Q. And in your current position, what do your
13 duties include?
14 A. So from a very high level, I oversee the
15 business units that I spoke of earlier. I work with
16 the operational managers, who run and oversee those
17 operations.
18 I work directly in line with the COO, Glenn
19 Kasprzyk, and several of our leadership team to oversee
20 some of the financial pieces of the operation, look at
21 deployment, staffing needs and requirements, call
22 volumes, all the way down to small day-to-day needs
23 from our operational staff, fleet needs, any host of
24 operational pieces in between there.
25 MS. FICKBOHM: Your Honor, I would move
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1 for admission at this time of LLA-13h.
2 MR. MEYERSON: No objection.
3 ALJ SHEDDEN: All right. 13h is
4 admitted.
5 BY MS. FICKBOHM:
6 Q. As part of your current job duties, is it
7 important for you to be aware of and involved in
8 CON 58's operations?
9 A. Yes, it is.
10 Q. There has been some discussion about American
11 Medical Response, and I'm going to use air quotations
12 to say operating CON 58 starting in October of 2015.
13 Can you clarify what that did involve and
14 what that didn't involve?
15 A. When the initial transfer took place, we were
16 kind of in a status quo environment.
17 Q. When you say "transfer," let talk -- let's
18 distinguish, first, between American Medical Response's
19 purchase of the Rural/Metro stock, as opposed to the
20 transfer of the CONs that Rural/Metro held in Arizona.
21 Did those occur at two different times?
22 A. Yes.
23 Q. And did the purchase occur first?
24 A. Yes.
25 Q. And when was that?
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1 A. In January. I don't know the exact date.
2 Q. I'm talking about not the transfer of the
3 CONs. The purchase by AMR of Rural/Metro stock.
4 A. Okay, reask your question. I'm sorry.
5 Q. Sure.
6 So we have the transfer of the CONs that
7 proceeded via a hearing after the purchase, correct?
8 A. Correct.
9 Q. So the purchase of the Rural/Metro stock
10 was -- the commitment was finalized on or about when in
11 2015?
12 A. I would have to look at the dates. October,
13 I believe.
14 Q. Okay. And -- but then pursuant to Arizona
15 law, there had to be permission by the Department of
16 Health Service to actually get the transfer of the
17 CONs, correct?
18 A. Correct.
19 Q. And that occurred when in 2016?
20 A. Late February, I believe.
21 Q. And I think that we actually have --
22 A. You may have the document.
23 Q. -- some documents that can give you that.
24 It's not a memorization test. We'll give you the
25 precise time frame.
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1 I'm pulling up the Director's final decision
2 in the transfer. Do you recognize that document?
3 A. Can you scroll down?
4 Q. Sorry. Yeah.
5 A. Yeah, I recognize it.
6 Q. Oops. Sorry.
7 A. January 26, 2016.
8 MS. FICKBOHM: Your Honor, I would move
9 for admission of AMR-5c.
10 MR. MEYERSON: No objection.
11 ALJ SHEDDEN: And I'm sorry, that was
12 5c?
13 MS. FICKBOHM: I'm sorry. LLA-5c.
14 ALJ SHEDDEN: All right. Life Line 5c
15 is admitted.
16 BY MS. FICKBOHM:
17 Q. So between the Director authorizing the
18 transfer of all of the Rural/Metro entity-held CONs --
19 which would include CON 58, correct?
20 A. Yes.
21 Q. -- and the AMR purchase of Rural/Metro's
22 stock with certain contingencies, by your recollection,
23 sometime in October, to what extent was AMR able to
24 operate CON 58 or any other CON that was
25 Rural/Metro-held in Arizona?
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1 A. It was my understanding that we were in a
2 status quo type operation, which meant we didn't change
3 staffing, leadership, or make any changes to the
4 operation at that point.
5 Q. And what was the visibility for you of the
6 finances, et cetera?
7 A. I had no visibility of the finances. That
8 was much, much farther above my pay grade.
9 Q. So it was your job to just maintain the
10 status quo?
11 A. It was our job to maintain status quo and
12 make sure that anything didn't go awry.
13 Q. We'll get back to CON 58. I wanted to cover
14 a couple other topics first.
15 As part of your professional history and your
16 ongoing duties, do you like to keep up on what's going
17 on with the Arizona Fire Districts, especially those
18 that hold CONs?
19 A. We have several fire partners around the
20 state of Arizona, so I'm always trying to stay up on
21 current affairs. I work with a lot of them side by
22 side. So it makes sense to do that.
23 Q. And in particular, do you have some pretty
24 in-depth experience with the Fire Districts that are
25 out in the west -- the more rural, but western part of
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1 the state?
2 A. I would say that's where most of my time has
3 been spent, that would be correct.
4 Q. Okay. So tell us about how some of those
5 Fire Districts are doing with regard to CONs they hold.
6 How is Lake Mohave Ranchos doing?
7 A. Lake Mohave Ranchos is a small District that
8 came out of a bankruptcy. They ran an operation of
9 three rescues or ambulances with transport
10 capabilities. They operated for a long time.
11 They actually at one point approached us
12 about taking their service over because of their
13 struggles. This was very apparent in 2010, '11, kind
14 of as the recession -- kind of towards the middle of
15 the recession. They lost their Fire Chief. We were
16 pretty clear about what they could do fiscally. We
17 actually sat down with them on a financial analysis
18 with them and reviewed what they could successfully run
19 there, and they didn't feel that they wanted to do
20 that.
21 So sometime after our conversations, they
22 ended up going into bankruptcy. They lost the Chief.
23 They ended up going to the County to basically bail
24 them out to make wages. They did a dramatic reduction
25 of staffing and took their transport capabilities from
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1 three down to one.
2 Q. And you're referring to ambulances?
3 A. Ambulances, yes.
4 We have a backup agreement with them. We
5 provide a lot of service for them. They were actually,
6 during their bankruptcy phase, being run by the
7 Northern Consolidated Fire Department, which the Chief
8 is Pat Moore, and I believe Pat Moore was either the
9 president or directly involved with the Arizona Fire
10 Districts. He was helping run that through the help of
11 John Flynn, who is their lobbyist, and oversaw that for
12 the County.
13 Q. When you say "we backed them up," what CON
14 holder has been providing backup services to them since
15 the 2010-2011 period?
16 A. CON 94, River Medical, Incorporated, also dba
17 Life Line.
18 Q. And are there times that Lake Mohave Ranchos,
19 you know, doesn't have any availability to provide
20 ambulance transports?
21 A. That's the case.
22 Q. What about Bullhead City?
23 A. Bullhead City is a good fire partner of ours.
24 We have been doing several, for several years, backup
25 interfacility transports out of their market. They
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1 recently submitted a letter to their hospital saying
2 they weren't going to take interfacility transports
3 after a certain time at night unless they were
4 absolutely emergent, which puts the hospital in kind of
5 a lurch.
6 So through cooperation with that certificated
7 holder, we will respond in at a request from the
8 Bullhead City Fire Department and take transports out
9 of Bullhead City to other places. Most of those go
10 into Las Vegas. Some of them come back into Phoenix.
11 Q. And is that, again, the River Medical
12 organization?
13 A. That's the River Medical organization.
14 Q. What about the Fort Mojave Mesa Fire
15 District?
16 A. So Fort Mojave Mesa and Fort Mohave are three
17 agencies that are really tied in with Bullhead along
18 the river stretch there. There's another hospital
19 there called Valley View Hospital. It's a little bit
20 smaller facility, but they do -- they have the same
21 challenges there that the main hospital in Bullhead
22 has, is there's a lack of resources at night to take
23 interfacility transports, and they're commonly not
24 taken by the Fire-based providers, for a number of
25 reasons.
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1 So we end up taking those transports. Some
2 of them, unfortunately, we turn down because we're not
3 available. We don't build our deployment models around
4 their volume. So, unfortunately, some of those
5 patients are taken by helicopter that probably don't
6 need to go by helicopter.
7 Q. And these are all outside of River Medical
8 CON 94's certificated area?
9 A. That's correct.
10 Q. So it sounds like River Medical does quite a
11 bit of mutual aid?
12 A. That's fair to say.
13 Q. Can you quantify, like, the percentage of
14 work that it does, how much of that's mutual aid?
15 A. It would be hard to put a number on it. I
16 would say probably at least one call to sometimes three
17 calls a day. We work with other providers to do, you
18 know, mostly interfacility work, because we have the
19 CON for almost all of Mohave County and all of La Paz
20 County, so we're the primary provider there.
21 Q. Changing topics, there was quite a bit of
22 discussion by Chief Bathke about Christopher-Kohl's
23 Fire District being part of the consortium and I think
24 maybe even placement of a station there. I'm not sure
25 about the last part.
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1 But has Christopher-Kohl -- has the
2 Christopher-Kohl's Fire District's interest or lack of
3 interest in the Hellsgate application been a matter of
4 interest to you?
5 A. So since we first got into Payson or I myself
6 and some of my leadership got into Payson, I could
7 sense there was a little frost in the area of something
8 going on, so I've been hypersensitive to interactions
9 between Fire Departments, trying to meet with the Fire
10 Chiefs, find out what's going on.
11 I'm new to that area. Try to be, you know,
12 the new guy there. But it became very apparent that
13 the CON process was going on, so we became
14 hypersensitive to what things were going on with all
15 the Districts that were there and trying to manage and
16 look at -- either through myself or our employees
17 concerned have been looking at minutes or going to
18 board meetings and City Council meetings.
19 Q. So did you come to learn that the
20 Christopher-Kohl's Fire District's governing board was
21 going to consider at an official board meeting whether
22 or not to support Hellsgate's application for a CON?
23 A. Yes, one of my -- my operations manager was
24 made aware by an employee that he had gone to a board
25 meeting, at which time there was a discussion regarding
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1 a letter, a letter of support for the Hellsgate Fire
2 District.
3 Q. Was that in late November?
4 A. It was. I actually have that document in
5 front of me.
6 Q. And so you received an oral report of what
7 happened at that meeting?
8 A. I did. I received an oral report from
9 Mr. Baker, my operations manager, and asked him -- you
10 know, it's -- unfortunately, a lot of these
11 communities, both rural and suburban, I want to
12 validate what was said. So I asked Mr. Baker to obtain
13 some written documentation of that. I didn't want to
14 just go on hearsay.
15 Mr. Baker provided me with a copy of some
16 board minutes. They don't appear to be signed, but
17 they are board minutes on decisions made on that date,
18 November 21st of 2016.
19 Q. And what did the Christopher-Kohl governing
20 board decide on that date about the Hellsgate
21 certificate of necessity application?
22 A. It says here, "Payson rejected the
23 Certificate of Necessity. Basically, Hellsgate is
24 interested in starting an ambulance service. After
25 much discussion the Board determined that the
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1 current -- there is no current --" I'm sorry -- "that
2 currently there is little interest in this proposal.
3 Mark Haynes [sic] spoke to the issue. Karen Thornton
4 made a motion that at this time Christopher-Kohl --"
5 it's in initials, "CKFD Board does not see a need for
6 an additional certificated ambulance [sic]. Jeff
7 Daniels seconded the motion."
8 Q. And was the motion -- was the vote split?
9 A. No, it was a unanimous vote.
10 Q. Against?
11 A. Against it, right.
12 Q. Okay. Changing topics, I would like to ask
13 you to look at what's been marked as LLA-20, and ask
14 you if you recognize this document?
15 A. I do.
16 Q. And can you tell us what this is and how you
17 came to get a copy of it?
18 A. So shortly after the merger, as we started to
19 go through the merger --
20 Q. "The merger," what do you mean by that?
21 A. When AMR acquired, I'm sorry, the
22 acquisition, AMR acquired Rural/Metro, shortly
23 thereafter, within several months, the employees of the
24 Payson operation decided to form or actually become
25 part of the -- what is known as the legacy PMT,
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1 Professional Medical Transport, union or labor group,
2 the International Association of EMTs and Paramedics.
3 This letter is a letter addressed to the
4 Arizona Department of Health Services, and basically
5 talks through the fact that they're, you know -- they
6 want us, AMR, to keep it, and they are not in favor of
7 the current provider -- or I'm sorry, that Hellsgate
8 getting a CON.
9 Q. And let me ask you. These are people who
10 work for Southwest Ambulance?
11 A. These are people that work for the Payson
12 ambulance under the Life Line.
13 Q. Oh, the Payson.
14 A. That's correct.
15 Q. Okay. And it's a labor union, correct?
16 A. It is a labor union, that's correct.
17 Q. And does American Medical Response or the
18 Life Line Payson operation have the ability to control
19 what these union employees do, don't do, say, don't
20 say?
21 A. Within the Federal guidelines.
22 Q. In fact, at some times, do you find yourself
23 on the other side of the negotiating table with them?
24 A. I'm currently on the other side of the
25 negotiating table, that's correct.
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1 Q. And just for purposes of the record --
2 MS. FICKBOHM: Your Honor, would it be
3 helpful to have this read into the record, or no?
4 ALJ SHEDDEN: It's not been admitted
5 yet. I don't know that we need any document read into
6 the record.
7 MS. FICKBOHM: I would move for
8 admission of Exhibit LLA-20.
9 ALJ SHEDDEN: Is there any objection on
10 20?
11 MR. MEYERSON: No objection.
12 ALJ SHEDDEN: All right. 20 is
13 admitted.
14 MS. FICKBOHM: I just didn't know if
15 anybody wanted to take some time to read it.
16 Anybody want more time to read?
17 Okay, hearing no request...
18 BY MS. FICKBOHM:
19 Q. So, Mr. Valentine, when did you become able
20 to really start to take a good look at CON 58's
21 operations deeper than what you were permitted to look
22 at during the temporary operating phase at the end of
23 2015?
24 A. Pretty much the latter part of March of this
25 year.
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1 Q. Okay. And so tell us how you went about
2 doing that, what you saw, and what your impressions
3 were.
4 A. First of all, you know, I was the new guy in
5 the area. We -- I relied heavily on some of the local
6 knowledge and several of the employees that have worked
7 there for a long time.
8 I engaged our deployment team, through Doug
9 Jones and his group, to look at some demand analysis of
10 what is going on in the local area, trends that are
11 going on.
12 I asked Mr. Baker to look at some local
13 requirements and see how we were doing at the hospital,
14 tried to start some interactions with the hospital.
15 I engaged our local operations supervisor,
16 Mr. Brumbaugh, about, you know, things that were going
17 on in the area. He was pretty clear there were some
18 pretty interesting dynamics going on between the
19 Chiefs, and we -- you know, at which time we found out
20 that there was a CON application being revolved.
21 I did make -- myself, Mr. Kasprzyk, and
22 Mr. Karolzak, John Karolzak, met with the Payson Fire
23 Chief, I believe once in person, and I had a couple of
24 conversations with him on the phone.
25 From that point, you know, I found a couple
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1 of glaring items.
2 Q. Which remember?
3 A. One, there was a staffing shortage. It
4 appeared that they were having some challenges with
5 staffing, not unlike many both rural and urban
6 Departments looking for paramedics. There's a national
7 shortage of paramedics. We see it around the country.
8 The more rural those areas, it becomes a little harder
9 to staff.
10 The other challenges, I saw that a large
11 number of interfacility transports were being handled
12 by units coming out of the valley. Some of the other
13 challenges --
14 Q. "The valley" meaning the Maricopa area?
15 A. I'm sorry. Out of the Maricopa area.
16 Q. I know that people in Phoenix think that "the
17 valley" means Phoenix.
18 A. The great state of Maricopa.
19 Q. But there's other valleys in the state,
20 right?
21 A. Correct.
22 Q. Okay. So...
23 A. I noticed that they were having some
24 challenges with some of their equipment that needed
25 some refresh. I mean those are just some of the many
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1 things that we look at. There was also some scheduling
2 issues on current scheduling that they were doing that
3 didn't meet the current needs.
4 Q. And were you able to see all of this
5 immediately as of late March, or did this take time to
6 develop?
7 A. It takes time. I mean, one, you want to make
8 sure -- look, everybody's on edge when the new guy's in
9 town, the new sheriff's in town. So we baby-stepped
10 into it. But there was a lot of things going on in the
11 background that people just didn't see were going on,
12 such as, you know, uniforms and branding and a lot of
13 the things that take time to put together.
14 We started to put together the process of
15 what that was going to look like and put together a
16 project plan.
17 Q. So can you tell the Judge and the Department,
18 insofar as hard, physical equipment, capital
19 expenditures, what you directed be put into the system
20 after you got a look at what was going on there at
21 CON 58?
22 A. So part of the overall CON or the overall AMR
23 acquisition of Rural/Metro was to put, obviously,
24 vehicles into the market. And two of those vehicles
25 have been placed in the Payson market. I believe they
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1 went in service last month or maybe -- yeah, I believe
2 last month.
3 Q. And are these new ambulances?
4 A. They're brand-new ambulances.
5 Q. And, John, why not until last month?
6 A. It took time. They were only one of the
7 needs of Arizona, and we looked at things as a very
8 stairstep graduation. They were one of them that
9 needed them, and they got them as soon as we possibly
10 could get them there. We have two more additional
11 units coming that direction and a refresh on a
12 four-wheel drive vehicle that is much, much needed in
13 that market.
14 Q. And tell -- what do you mean by "a refresh on
15 a four-wheel drive vehicle"?
16 A. Off the top of my head, I'm not sure if it's
17 a brand-new four-wheel drive or it is a newer
18 four-wheel drive. I don't know if it's a 2013 or '14.
19 I don't know exactly. I don't have the capital list up
20 in front of me.
21 Q. And that's a four-wheel drive ambulance?
22 A. Correct.
23 Q. So how many ambulances does CON 58 have right
24 now?
25 A. There should -- there's usually between five
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1 and seven there, but we rotate some of those out for
2 PMs.
3 Q. What's a PM?
4 A. I'm sorry. That's just routine maintenance
5 on the vehicle, oil changes, tire changes. We utilize
6 a local shop for some small stuff; but if it's anything
7 large or a longer maintenance cycle, they'll come down
8 to the valley and have our own mechanics go through
9 those.
10 Q. So at any point in time there's five to seven
11 ambulances present?
12 A. Yes.
13 Q. And two of them are -- I think I understand
14 your testimony to be two are brand-new, and you have
15 two more new coming?
16 A. That's correct.
17 Q. And the two that are coming, are you going to
18 add those to what you have, or are you going to pull
19 old ones out?
20 A. No, those will replace old fleet.
21 Q. What about medical equipment; did you add any
22 medical equipment to the operation?
23 A. They were operating on a Zoll, which is the
24 brand name of a cardiac monitor, which was an older
25 platform, pretty much antiquated platform. We did a
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1 refresh on some Lifepak 12s, which are not a brand-new
2 monitor, but we felt it was a great stopgap to get them
3 onto the Lifepak platform that is commonly used in AMR
4 around the country. It gave them more state-of-the-art
5 equipment available to them.
6 Q. Did you update any software?
7 A. So there was a couple of different things
8 that were updated, and this is a lot of the pieces that
9 go on in the background that the employees don't see.
10 They've been moved over to our MEDS platform as of
11 about two months ago. The MEDS platform is our ePCR
12 platform. That's a proprietary electronic patient
13 record, which allows Payson to be included in the
14 Arizona SHARES data, report --
15 Q. SHARES or CARES?
16 A. I'm sorry, Arizona CARES data; and it
17 automatically dumps the data into that, as well as into
18 the Bureau for their EMS data collection as well.
19 Q. So -- and that was as of a couple months ago?
20 A. Couple months ago. We actually did the whole
21 Arizona market. As you can imagine, 1,800 employees,
22 it was quite an undertaking, both from a capital and
23 training piece.
24 Q. So will CON 58 be able to report annual
25 information into the CARES program that Dr. Racht
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1 talked about earlier this morning in calendar year --
2 for calendar year 2017?
3 A. It's happening as we speak. It will allow,
4 after we gather some data -- they run 220, 230 calls a
5 month. That's not a whole lot of data to gather.
6 After several months we'll be able to gather a lot more
7 and start to see where things are benchmarking, as
8 Dr. Racht spoke of earlier.
9 Q. Any other equipment or additions that you can
10 think of off the top of your head that you want to
11 bring up?
12 A. We've redone the scheduling. They have now
13 moved over to a TeleStaff scheduling platform, which is
14 our standard platform to do scheduling. It just gives
15 us a higher level of accountability for the employees,
16 and that's all done -- instead of being done locally in
17 Payson, that's being handled now out of our operation
18 in Mesa at the 22 West Main operation. So that gives
19 us a little bit more global. We've added -- we added
20 staff when --
21 Q. What staff did you add?
22 A. So we added staff. So we fully staffed three
23 24-hour ambulances in Payson with paramedic level and
24 then we added a fourth peak time truck. After
25 Mr. Jones and his team, Doug Jones and his team, put
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1 together some demand analysis and, really, after
2 reviewing a lot of these so-called 368 interfacility
3 transports that were coming from Payson and being
4 utilized by Maricopa units, we saw a need for a peak
5 demand truck that operates a 10-hour-a-day Tuesday,
6 Wednesday, Thursday and Friday. We also --
7 Q. And let me just stop you for a second.
8 We heard some testimony about CON 58 having
9 some of its ambulance staffed without having a
10 paramedic on board. Is that occurring now?
11 A. I'm not going to say it could never occur.
12 Payson's interesting to the fact that they do keep a
13 certification that is not kept around the state very
14 much, and that's an intermediate or an EMT-I.
15 They can be used in an ALS capacity, which
16 means they can start IVs and do advanced airways. They
17 don't carry all of the same drugs as a paramedic, and
18 they don't do all of the same interventions, but they
19 can be used in an ALS capacity. And in the past,
20 Payson has used intermediates with an EMT to run calls
21 if they had a staffing issue, a call-off, a sick call,
22 or maybe there was even a callback.
23 Q. What's a callback?
24 A. Commonly in a lot of these small rural areas,
25 they have a system where they'll call back employees if
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1 all the units go out or they had an extraordinary bad
2 event, such as --
3 Q. So you're referring to calling off-duty
4 employees back?
5 A. Calling, yeah, off-duty employees back in.
6 And, you know, if that -- if they came back and staffed
7 an ambulance with an EMT and an I, they would still be
8 an ALS unit. They just wouldn't have a paramedic on
9 board.
10 Q. And how often, to the best of your knowledge,
11 is CON 58 having to look to use of an EMT-I as opposed
12 to a paramedic these days?
13 A. I don't think we're using them very often.
14 Right now those intermediates are being used in
15 conjunction with a paramedic on a car. That's the way
16 they're staffed and scheduled currently. So all four
17 units are staffed paramedic level with EMTs or I-EMT
18 drivers.
19 Q. Okay. So I think -- I guess I was thinking
20 paramedic and an EMT. You're saying that all of them
21 have two paramedics or one paramedic with an EMT-I?
22 A. No.
23 Q. Okay.
24 A. They're all staffed with either an EMT and a
25 paramedic or an EMT-I and a paramedic.
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1 Q. Okay. Thank you.
2 A. Yeah.
3 ALJ SHEDDEN: Let me ask. We're right
4 about a quarter of. If you want to wrap up an area of
5 questioning, that would be probably a good idea. If
6 this is a good place to stop, that works for me as
7 well.
8 MS. FICKBOHM: Yeah. Let me just ask
9 Mr. Valentine to tell us when the staffing of vehicles
10 was upped, and I can -- that would be -- so I don't
11 pick up with a trailing question tomorrow morning.
12 BY MS. FICKBOHM:
13 Q. So when was this staffing upped on the
14 vehicles?
15 A. So as of October 29th, after negotiations
16 with our labor group, we went into service with the
17 fourth unit with that peak time deployment.
18 Q. And when did you move to making sure that
19 every ambulance transport unit had a paramedic on it?
20 A. That was a process over a few months of
21 hiring.
22 Q. And you already told us why hiring isn't
23 something that can happen overnight?
24 A. Yeah, it just doesn't happen overnight, so...
25 Q. Is it easier to recruit paramedics to urban
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1 areas?
2 A. It is. Sometimes you get more skilled older
3 paramedics that like to go to these slower -- slower
4 911 services, but like the medicine that happens in
5 these very rural areas. The call volume is not as
6 much, but the medicine that they get to provide is much
7 more needed sometimes.
8 MS. FICKBOHM: Your Honor, this would be
9 a good place for us to break.
10 ALJ SHEDDEN: All right. Let me just
11 let you know that what my records are showing is one
12 exhibit, Life Line 9, which was the tax rate
13 information that Mr. Maguire was testifying about, I
14 don't show that as having been admitted. So either I
15 missed that or it was not offered.
16 Was it your intention to offer that?
17 MS. FICKBOHM: No. I'll offer that
18 during Mr. Kasprzyk's testimony, since he put it
19 together. But thank you, Your Honor.
20 ALJ SHEDDEN: All right.
21 MS. FICKBOHM: I got all my resumés
22 requested today, didn't I?
23 ALJ SHEDDEN: That, I think so, the
24 ones -- I try and only write down the ones I didn't
25 see.
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1 MS. FICKBOHM: Okay.
2 ALJ SHEDDEN: So is there anything we
3 need to address, or we'll just reconvene tomorrow
4 morning?
5 MR. RAY: Judge, just so everyone is
6 aware, this afternoon our staff delivered the missing
7 ADHS exhibit. So hopefully it will be uploaded tonight
8 and available tomorrow.
9 ALJ SHEDDEN: All right. Thank you.
10 All right. We'll see everyone tomorrow.
11 (The hearing adjourned at 4:46 p.m.)
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1 STATE OF ARIZONA ) COUNTY OF MARICOPA )
2
3 BE IT KNOWN that the foregoing proceedings were taken before me; that the foregoing pages are
4 a full, true, and accurate record of the proceedings, all done to the best of my skill and ability; that
5 the proceedings were taken down by me in shorthand and thereafter reduced to print under my direction.
6 I CERTIFY that I am in no way related to
7 any of the parties hereto, nor am I in any way interested in the outcome hereof.
8 I CERTIFY that I have complied with the
9 ethical obligations set forth in ACJA 7-206(F)(3) and ACJA 7-206 (J)(1)(g)(1) and (2). Dated at
10 Phoenix, Arizona, this 31st day of December, 2017.
11
12 _______________________________________
13 JODY L. LENSCHOW, RMR, CRR Certified Reporter
14 Arizona CR No. 50192
15 I CERTIFY that Coash & Coash, Inc., has
16 complied with the ethical obligations set forth in ACJA 7-206 (J)(1)(g)(1) through (6).
17
18
19
20
21
22
23 _______________________________________
24 COASH & COASH, INC. Registered Reporting Firm
25 Arizona RRF No. R1036
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