American Medical Response ambulances park at the Santa Barbara Cottage Hospital. The county put its ambulance service contract out to bid and potential bidders include AMR and the County Fire Department.
American Medical Response ambulances park outside Santa Barbara Cottage Hospital. The county is about to open permit applications for ambulance services providers. Credit: Giana Magnoli / Noozhawk file photo

American Medical Response’s regional director said the company was “blindsided and disappointed” by Santa Barbara County’s decision to create a permit-based ambulance services system rather than choosing a single, exclusive provider.

Mike Sanders submitted a comment letter this week to the county Board of Supervisors, which approved a new system for picking ambulance providers.

“It creates instability for providers and our local hospitals, places rural areas and other areas with lower call volume at risk, and establishes a novel, untested method for running an ambulance system that is contrary to the applicable state law found in the EMS Act,” Sanders wrote.

He argued that the ordinance “gives your board considerably more authority than California’s EMS Act authorizes.”

The supervisors pursued an exclusive contract for services countywide, but abandoned that after a request-for-proposals process that scored AMR higher than the county Fire Department.

Instead, they approved a non-exclusive contract system, and gave themselves the authority to choose future providers.

AMR has provided ambulance services to most of the county for about 50 years, and County Fire has ambulance crews serving the three areas AMR doesn’t: Vandenberg Village, the Cuyama Valley and UC Santa Barbara.

Public Health Director Dr. Mouhanad Hammami presented the new system at the June 6 meeting.

The Board of Supervisors has the final say in issuing three types of permits: responding to 9-1-1 emergency medical calls; interfacility transfers and staffing for special events such as festivals; and critical-care transfers.

The supervisors approved the new ordinance on a 5-0 vote at that meeting, and gave it final approval with a 4-0 vote on Tuesday. Das Williams, Joan Hartmann, Steve Lavagnino and Bob Nelson voted for it, and Laura Capps was absent.  

The ordinance goes into effect on July 20, and then permit applications will be open for 21 days, according to Emergency Medical Services staff at the Public Health Department.

They estimate it will take three or four weeks to review applications, until about mid-September, and the permits will go to the Board of Supervisors for review and approval after that.

The county hopes to have new contracts in effect by March 2024, when the current AMR contract expires, Hammami said.

Hospital CEOs: Don’t Forget About Transports Between Facilities

In early June, hospital system CEOs wrote a letter to each county supervisor with concerns about the new system’s ability to provide 24-7 access to interfacility transfers and critical care transports, which take patients between hospitals.  

Most of the discussion and debate around the ambulance contract has centered on 9-1-1 call emergency medical response, not the thousands of trips between health facilities each year.

“The system must ensure that medically necessary, albeit unprofitable, (inter-facility transfers and critical care transports) must still be provided in a manner that retains or improves existing standards of care,” wrote Ron Werft, president and CEO of Cottage Health; Sue Anderson, president and CEO of Marian Regional Medical Center; and Steve Popkin, CEO of Lompoc Valley Medical Center.

Last year, ambulances delivered more than 31,000 patients to local hospitals, they wrote.

“Almost 5,000 patients were transported between one hospital and another, including hundreds of psychiatric transports to facilities in Bakersfield, Los Angeles and beyond,” they wrote in the letter. “There were 356 critical care transports that connected patients to a higher level of life-saving care.” 

As Noozhawk has reported, the county spends millions of dollars sending mental health patients to out-of-county psychiatric facilities when local beds are full, which they are almost every day.

Santa Barbara Cottage Hospital has a Level I trauma center, and Marian Regional Medical Center has a Level II trauma center, which means critically injured patients can be transferred there from other local hospitals.

“Lastly, hospitals want to voice concern for residents in remote, rural, and underpopulated areas of the county,” the hospital CEOs letter said. “Timely access to emergency services and maintaining response times for outlying communities are important; in some cases, every minute matters.

“The health of our community depends upon a robust response by all ambulance providers serving the county.”

When Capps asked about the concerns raised by the letter during the June 6 meeting, Hammami said the county has a mandate to provide interfacility transfers, which won’t change.

“It was just the clarification of whether there will be dedicated ambulances for that IFT and what happens after hours, and we assured the hospitals and the CEOs that this is still the case as it is being provided now,” Hammami said.

AMR Letter Outlines Objections to Permit-Based System

Sanders, regional director of AMR for Santa Barbara and Ventura counties, argued in his comment letter that moving the designated Emergency Medical Services Agency authority from Public Health to the county Fire Department “would effectively put the losing bidder in charge of any potential ambulance ordinance permit holder.”

AMR’s proposal for an exclusive contract had innovative investments into the system, he wrote in his letter. The proposal was scored higher than County Fire’s proposal by all five review panel members.  

“Finally, this decision especially does not make sense when the current system provided by AMR has been significantly stable throughout the life of its contracts,” Sanders wrote to the Board of Supervisors.

“Santa Barbara County has some of the best cardiac arrest save rates in the nation, and AMR’s paramedics and EMTs are a direct result of that.”

Since about 80% of fire department calls are medical calls, it makes sense for the Fire Department to provide ground ambulance services, local fire chiefs have argued during the bidding process.

They’ve continually argued that giving County Fire the contract would improve response times to emergency medical calls. They also made a website promoting that idea:

“The plan that County Fire has developed is a more robust system with more ambulances on the street. It would be accountable to the community, absolutely transparent to the community,” Santa Barbara City Fire Chief Chris Mailes said during a March rally showing support for the County Fire bid proposal.

“You might hear (people say) that it’s incredibly complex — it’s not. It’s not incredibly complex. Your firefighters all over the county respond to EMS calls every single day. The only thing we’re adding into the system under the fire department umbrella is the transport. … It would just simply be a win for the community.”

At the meeting a week later, the Board of Supervisors decided to pursue non-exclusive contracts for ambulance services.