REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
REPORT/RECOMMENDATION TO THE BOARD OF DIRECTORS
OF THE INLAND COUNTIES EMERGENCY MEDICAL AGENCY
AND RECORD OF ACTION
December 5, 2023
FROM
LUTHER SNOKE, Chief Executive Officer, County Administrative Office
DANIEL MUÑOZ, Interim EMS Administrator, Inland Counties Emergency Medical Agency
SUBJECT
Title
Contract for Ground Ambulance Medical Transportation Services
End
RECOMMENDATION(S)
Recommendation
1. Acting as the governing body of San Bernardino County:
a. Approve one of the following contracts to provide Advanced Life Support, Basic Life Support, ground ambulance services, and Interfacility and Critical Care Transport services to various Exclusive Operating Areas within the County, as informed by the parameters in the Request for Proposals, which includes the highest scoring proposal that demonstrates the best value and meets the needs of the County, for a five-year initial term, with an option to extend the contract for a second five-year term:
i. American Medical Response, for an initial term of April 1, 2024 through March 31, 2029; or,
ii. The Consolidated Fire Agencies, and its private subcontractor Priority Ambulance, for an initial term of October 1, 2024 through September 30, 2029.
b. Approve the Memorandum of Understanding between the County and the Inland Counties Emergency Medical Agency to provide oversight and monitoring of the ground ambulance services contract and assign the contract service charge payments received from the contractor, directly to the Inland Counties Emergency Medical Agency, for the cost of oversight and monitoring the contract.
2. Acting as the governing body of Inland Counties Emergency Medical Agency:
a. Approve the Memorandum of Understanding between the County and the Inland Counties Emergency Medical Agency to provide oversight and monitoring of the ground ambulance services contract and receive service charge payments directly from the contractor, for the cost of oversight and monitoring the contract.
b. If the Consolidated Fire Agencies contract is approved by the County, authorize the Inland Counties Emergency Medical Agency Executive Officer to approve and execute Amendment No. 10 to the existing American Medical Response Contract No. 12-254 for Advanced Life Support ambulance services, extending the term of the contract from April 1, 2024 through September 30, 2024, subject to County Counsel review.
c. Direct the Inland Counties Emergency Medical Agency Executive Officer to submit Amendment No. 10 to Contract No. 12-254 to the Secretary of the Board of Directors within 30 days of execution.
(Presenter: Luther Snoke, Chief Executive Officer, 387-4811)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
Operate in a Fiscally-Responsible and Business-Like Manner.
Provide for the Safety, Health and Social Service Needs of County Residents.
FINANCIAL IMPACT
Approval of this item does not impact Discretionary General Funding (Net County Cost), as ambulance services are billed to third parties and do not directly generate revenue or expense to San Bernardino County (County). However, under the contract, the awarded agency will be required to pay the County a contract monitoring service charge of $1,800,000 for the first year, with annual adjustments based on the Consumers Price Index. In addition, approval of Recommendation Nos. 1.b. and 2.a. will approve a Memorandum of Understanding (MOU) between the County and the Inland Counties Emergency Medical Agency (ICEMA), where ICEMA will provide oversight of the ambulance services contract, and service charge payments will be made directly to ICEMA from the contractor. Should the Consolidated Fire Agencies (CONFIRE) be awarded the contract, Recommendation No. 2.b. will extend the existing American Medical Response (AMR) ambulance contract for six months during the period of transition to the new ambulance services provider.
BACKGROUND INFORMATION
ICEMA, acting in its capacity as the County’s local Emergency Medical Services (EMS) agency, drafted an EMS plan approved by the State EMS Authority that established Exclusive Operating Areas (EOAs) for 911 Advanced Life Support (ALS) ground ambulance transportation services and inter-facility medical transportation needs, as allowed under California Health and Safety Code (H&S), Division 2.5 Emergency Medical Services, and sections 1797.76, 1797.85, 1797.103, 1797.224, and 1797.226. A total of 26 EOAs currently exist within the County.
AMR, and its predecessor companies, has been providing ambulance services under contract with the County since the late 1970s. The County has not historically released a Request for Proposals (RFP) to competitively procure an ambulance provider for these EOAs, but rather utilized a grandfathered process authorized pursuant to H&S sections 1797.224 and 1797.226.
Pursuant to H&S Section 1797.224, when a local EMS Plan includes EOAs, a competitive process, approved by the State EMS Authority, may be used for selecting EMS providers and determining the scope of operations. On December 20, 2022, the County released an RFP that was approved by the State EMS Authority, inviting prospective providers to submit proposals to provide ground ambulance services in 11 of the County’s 26 EOAs, which include EOAs 1, 2, 3, 4, 5b, 6, 7, 8, 9, 11, and 12a (known collectively as the Comprehensive Service Area). The Comprehensive Service Area encompasses the majority of the San Bernardino County valley, as well as parts of the high desert and mountain regions, reflecting urban, suburban, rural, and wilderness areas.
Proposers were required to meet minimum technical and financial requirements to be considered for the contract award, which included five years of experience (within the past seven years), providing 911 ALS transport services for a large urban area with a population greater than 1,000,000, which included a mix of urban, suburban, rural and wilderness areas. In addition, the RFP outlined substantial high-performance criteria to ensure the contractor is held accountable to several service quality metrics, including meeting response time thresholds and clinical performance standards.
Private and public entities were allowed to submit proposals, including public Joint Powers Authorities (JPA) using a private ambulance subcontractor. Two proposals were received by the submission due date of April 6, 2023, from AMR and the CONFIRE JPA. The CONFIRE JPA consists of public entities (cities and fire districts) from Apple Valley, Chino, Colton, Loma Linda, Rancho Cucamonga, Redlands, Rialto, Victorville, and the San Bernardino County Fire Protection District (SBCFPD). As such, pursuant to the CONFIRE JPA Agreement, if the contract is awarded to CONFIRE, there could be a financial impact to the SBCFPD because the JPA Agreement provides that each JPA Member entity is responsible for its proportionate share of CONFIRE’s underfunded financial obligations, if any were to occur. CONFIRE’s proposal includes a subcontractor private entity, Priority Ambulance. AMR is solely a private entity.
An independent review panel made up of four evaluators individually scored each proposal on 14 key areas as detailed in the Procurement section, for the purpose of making a recommendation to the County for final negotiation of contract terms. The total cumulative scores were a difference of less than a quarter of 1% between the two proposals.
The RFP states that the County will award a contract based on the highest scoring proposal that demonstrates the best value and meets the needs of the County. AMR accumulated a slightly higher amount of aggregate points. However, because the scores were substantially equivalent, the County Administrative Office (CAO) is providing both contracts for Board of Supervisors (Board) consideration. Per County Policies 11-06 and 11-04 respectively, the Board has the sole and ultimate authority to select and approve a contract for services which provides the best value and best protects the interests of the County.
Each contract outlines how the contractor will provide emergency ground ambulance services throughout the Comprehensive Service Area, and includes:
• Response time requirements.
• Clinical Performance Standards.
• Development of an annual deployment plan detailing the number of weekly unit hours and staffed ambulances needed for emergency and Interfacility Transport (IFT) responses.
• Personnel and staffing considerations, including details about the organization’s key leadership, compensation/benefits, training, and wellness programs.
• Data reporting and performance tracking.
• Fiscal requirements, including pricing, billing, and fees.
• Breach and emergency takeover provisions.
The AMR proposal included the following details:
• 12,889 weekly unit hours will be scheduled to respond to calls.
• 111 ambulances will be available during peak system demand and stationed throughout the Comprehensive Service Area, with 39 additional ambulances available to meet system surges.
• AMR is the current Comprehensive Service Area provider, with existing locations, personnel, and vehicle infrastructure in place.
• Key leadership is already assigned to the area and consists of:
o 10 managers and 18 field supervisors among the three regions (Rancho Cucamonga, Victorville, and Redlands).
o All operations are overseen by a Regional Director of Operations, along with an AMR Medical Director.
• Vehicles are fully equipped and currently in use.
• Addition of a mobile training vehicle and a Medical/Health Mobile Command and Communication vehicle to support public safety during a disaster. The vehicles can be used by EMS stakeholders throughout the county, including the Department of Public Health.
• Available to start as of April 1, 2024, upon the expiration of the current contract.
Proposed AMR Patient Fee Rates include:
|
Type |
Base Rate |
|
ALS/Basic Life Support (BLS) |
$3,958 |
|
IFT |
$2,834 |
|
Critical Care Trasport (CCT) |
$4,392 |
The CONFIRE proposal included the following details:
• 10,371 weekly unit hours will be scheduled to respond to calls.
• 93 ambulances at peak demand and stationed throughout the Comprehensive Service Area, with 45 additional ambulances available to meet system surges.
• Subcontracting with Priority Ambulance, one of the nation’s largest ambulance services, primarily serving the State of Arizona, in Maricopa County including the metropolitan Phoenix area. CONFIRE will establish locations, on-board personnel, and acquire vehicles upon award.
• Key leadership will include management from both Priority Ambulance and CONFIRE.
• Leadership to be recruited upon contract award and will consist of:
o Nine managers and 18 operations supervisors among the three regions (Eastern, Western, and High Desert).
o Directors will be appointed for EMS Operations and Communications, as well as a Medical Director.
• Vehicles and equipment will be purchased upon award.
Proposed CONFIRE Patient Fee Rates include:
|
Type |
Base Rate |
|
ALS |
$3,547 (non-emergency/IFT) / $4,053 (emergency) |
|
BLS |
$2,533 (non-emergency) / $3,167 (emergency) |
|
CCT |
$5,067 |
Note: IFT charges will be billed as ALS/BLS emergency/non-emergency services as provided.
Lastly, the CAO recommends approval of the MOU between the County and ICEMA as listed in Recommendation Nos. 1.b. and 2.a., as ICEMA is the regulatory agency for ambulance services in the county. By approving the MOU, ICEMA will provide performance oversight to the contractor and collect service charge payments directly.
PROCUREMENT
On December 20, 2022, the Purchasing Department (Purchasing) issued RFP No. ICEMA23-ICEMA-4811 through the County Electronic Procurement Network (ePro) in accordance with H&S Section 1797.224 and sent notifications, through email and the United States Postal Service, of the RFP to eight local, state, and national ambulance and firefighter associations.
Proposals were evaluated on 14 key areas, which included system requirements, response time standards, clinical performance, deployment plans, vehicles, medical supplies and equipment, personnel, hospital and community requirements, disaster preparedness/response, quality management, electronic patient care reports, centralized emergency medical dispatch center, financial and administrative requirements qualifications, and future system enhancements.
The evaluation panel received a presentation from each bidder where clarifying questions were asked, and met as an evaluation group before arriving at the final scores. Final scores resulted in a four-point difference out of a possible 1,720 total points and three out of the four evaluators ranking CONFIRE above AMR, which indicated both proposers were evenly qualified and able to provide emergency ambulance services.
|
Proposal Scores |
|
|
Evaluator 1 |
Evaluator 2 |
Evaluator 3 |
Evaluator 4 |
TOTAL |
|
AMR |
373 |
419 |
346 |
381 |
1519 |
|
CONFIRE |
383 |
384 |
363 |
385 |
1515 |
On June 5, 2023, Purchasing emailed each proposer a Notice of Intent to Negotiate. The letter informed each agency that due to the substantially equivalent scores, both proposers were being given notice to move forward with contract negotiations and that the final contract approval rests with the Board.
On October 27, 2023, Purchasing emailed AMR a Notice of Intent to Award (NOIA), as AMR’s proposal received a slightly higher aggregate score from the evaluation panel, therefore triggering the NOIA procedure in the RFP.
One protest was received from AMR within the 10-day protest period, which ended on November 6, 2023. AMR alleged that the County has 1) failed to follow the selection procedures and adhere to requirements specified in the RFP, and 2) otherwise violated State and/or Federal law, as its grounds for protest. The Purchasing Agent reviewed and considered the protest and notified AMR of its decision to deny the protest. The decision of the Purchasing Agent concerning the protest is deemed final and constitutes the sole administrative remedy available to the proposer under the RFP.
These contracts comply with Resolution No. 2023-161, establishing a County policy regarding ambulance service contracts adopted by the County on August 22, 2023 (Item No. 32), pursuant to H&S section 1797.230 (Assembly Bill 389).
REVIEW BY OTHERS
This item has been reviewed by County Counsel (John Tubbs II, Deputy County Counsel, and Julie Surber, Principal Assistant County Counsel, 387-5455) on November 20, 2023; Inland Counties Emergency Medical Agency (Amber Anaya, Assistant EMS Administrator, 388-5824) on October 27, 2023; Purchasing (Ariel Gill, Supervising Buyer, and Leo Gomez, Purchasing Manager, 387-2070) on October 24, 2023; Risk Management (Victor Tordesillas, Director, 386-8623) on October 27, 2023; Finance (Erika Rodarte, Administrative Analyst, 387-4919) on October 27, 2023; and County Finance and Administration (Robert Saldana, Deputy Executive Officer, 387-5423) on October 27, 2023.