EMS SYSTEM COORDINATION - California Fire Chiefs ...

EXHIBIT 4

EXHIBIT A

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY ARNOLD SCHWARZENEGGER, Governor

EMERGENCY MEDICAL SERVICES AUTHORITY 1930 9th STREET

SACRAMENTO, CA 95811-7043 (916) 322-4336 FAX (916) 324-2875

EMS SYSTEM COORDINATION

AND HS 1797.201 IN 2010

EMSA 310-01 April 2010

EMS SYSTEM COORDINATION AND HS 1797.201 IN 2010

Prepared by California Emergency Medical Services Authority staff as a discussion document for the EMS System Coordination Workshop on May 4, 2010

R. Steven Tharratt, M.D., MPVM Director

Daniel R. Smiley Chief Deputy Director

June Iljana Deputy Director

Steven McGee Senior Staff Counsel

Bonnie Sinz Chief, EMS Systems Division

Donna Nicolaus Manager, EMS System Unit

Tom McGinnis Transportation Coordinator

April 2010


Table of Contents

SECTION I: INTRODUCTION …………………………………………………… 1 SECTION II: ORGANIZATION OF EMS COORDINATION IN CALIFORNIA …. 3 SECTION III: HEALTH AND SAFETY CODE 1797.201 – WHAT DOES IT MEAN in 2010? .............................................. 9 SECTION IV: PREHOSPITAL EMS --TYPE AND LEVEL OF SERVICE …..…. 16 SECTION V: AMBULANCE ZONE EXCLUSIVITY ………………………….…19 SECTION VI: OBSERVATIONS AND CONSIDERATIONS …………….……. 23

EMS System Coordination and HS1797.201 in 2010 California Emergency Medical Services Authority Page 1


SECTION I: INTRODUCTION

The California Emergency Medical Services Authority (EMSA) is the State agency responsible for the development and coordination of emergency medical services statewide. The primary goal of the current scheme for regulating emergency medical services (EMS) in California is to achieve a coordinated system that serves the public with effective and efficient EMS services. The fire service has presented a position paper regarding their role in a coordinated and integrated EMS system. As a result of disputes between some local EMS agencies (LEMSA) and some cities and fire districts, a singular provision in the Health and Safety code is being presented as a rationale by the fire service for their independence in a coordinated and integrated local EMS system. These issues give EMSA the opportunity to carefully discuss and respond to the important questions raised now 30 years after passage of the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act (EMS Act) in 1980. EMSA has further reviewed the California Health and Safety Code1, the California Code of Regulations2 and various clarifying court cases. The issues related to EMS System coordination and the impact of Health and Safety Code 1797.201 appear to have been already substantially answered by the California Supreme Court in its opinions contained in the cases of County of San Bernardino v. City of San Bernardino, 15 Cal. 4th 909 (1997)3 (the “San Bernardino decision”), and Valley Medical Transport v. Apple Valley Fire Protection District, 17 Cal. 4th 747 (1998)4 (the “Apple Valley decision”). Additionally, the Appellate Court decision in City of Petaluma v. County of Sonoma, 12 Cal. App. 4th 1239 (1993)5 (the “Petaluma decision”) is illustrative. In this document, EMSA relies extensively upon the clarification given in these decisions. This document further will identify some limited solutions to the ongoing discussion related to the application of section 1797.201 in light of the overarching legislative intent to have a coordinated and integrated EMS system in 2010.

Three specific recommendations will be identified for consideration as part of this document:

1. Agreements should be reached between a local EMS agency and an eligible city or fire district under 1797.201, for those areas that have not already done so, that specify and clearly articulate the type of service and role in the EMS system. 2. Local EMS plans should include a review and verification of what constitutes a section 1797.201 city or fire district, and at what type of prehospital EMS service, as part of an EMS plan that is submitted to EMSA for approval. 3. A local Emergency Medical Care Committee should be required at the local EMS level to ensure meaningful involvement by EMS system participants.

Agreements continue to form the basis of the development of

an effective and efficient EMS system, and those agreements should clearly identify the role of a city or fire district. These agreements which are mutually satisfactory can serve to decrease future conflict if certain rights can be clearly articulated. On its surface, the issue now presented appears to be a fairly isolated issue. EMSA is unaware of substantial service disagreements between the fire service and local EMS Agencies in the area of the provision of paramedic services or ambulance services. Our observation that the core issue today is related to dispatch, and whether HS 1797.201 contemplated “dispatch” as a prehospital type of service and to what extent medical control impacts the decision about who may perform emergency medical dispatch as part of an EMS system. Meaningful involvement by all EMS system participants in the EMS planning process will assist in building trust and collaboration.



SECTION II:

ORGANIZATION OF EMS COORDINATION IN CALIFORNIA The proper starting point for discussion of these issues is an understanding of the EMS Act. As the Court in Apple Valley reiterated from the San Bernardino case, "the EMS Act contain[s] 100 different provisions in 9 separate chapters and create[s] a comprehensive system governing virtually every aspect of prehospital emergency medical services.6 The Legislature's desire to achieve coordination and integration is evident throughout. The EMS Act accomplishes this integration through what is essentially a “two-tiered system of regulation." California’s “Two Tiered System of Regulation” The two tiers of regulatory oversight consist of a state Authority, which "performs a number of different functions relating to the coordination of EMS throughout the state", and an EMS agency established by a county, or a joint powers agency of counties or counties and cities, which plans, implements, and evaluates emergency medical service systems on a countywide or multicounty basis, and which maintains " '[t]he medical [control] and management of an emergency medical services system.' "7 As the court viewed the EMS Act, the statute and relevant regulations "broadly mandate that the local EMS agency formulate medically related policies and procedures to govern EMS providers."8 What is EMSA’S role? Emergency medical services in California began with the passage of the Wedworth-Townsend Pilot Paramedic act in 1980.9 The Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act (EMS Act) was passed in 1980 to institutionalize the provision of emergency medical services.10 Consequently, EMSA was established as a mechanism to form a statewide EMS system. It is headed by a physician director who has substantial experience in emergency medicine.11 The mission of the California Emergency Medical Services Authority (EMSA) is to ensure quality patient care by administering an effective, statewide system of coordinated emergency medical care, injury prevention, and disaster medical response. Both Health and Safety code 1797.1 and 1797.78 articulate the critical nature of coordination and integration for EMS services.


1797.1. The Legislature finds and declares that it is the intent of this act to provide the state with a statewide system for emergency medical services by establishing within the Health and Welfare Agency the Emergency Medical Services Authority, which is responsible for the coordination and integration of all state activities concerning emergency medical services.

1797.78. "Emergency medical services system" or "system" means a specially organized arrangement which provides for the personnel, facilities, and equipment for the effective and coordinated delivery in an EMS area of medical care services under emergency conditions.

In performing these duties, the EMS Authority utilizes statutes, regulations, and guidelines as a basis for its oversight of the EMS system in California as directed in Health and Safety code 1797.103 and 1797.107. EMSA’s duties include the development and implementation of standards and guidelines for EMS systems and reviewing and approving local emergency medical services plans submitted by local emergency medical services agencies (LEMSAs) based on these standards and guidelines as required in Health and Safety code 1797.250 and 1797.254.

1797.103. The authority shall develop planning and implementation guidelines for emergency medical services systems which address the following components: (a) Manpower and training. (b) Communications. (c) Transportation. (d) Assessment of hospitals and critical care centers. (e) System organization and management. (f) Data collection and evaluation. (g) Public information and education. (h) Disaster response.

As part of the methodology to ensure a coordinated EMS system, EMSA may create regulations to clarify any part of the EMS Act.

1797.107. The authority shall adopt, amend, or repeal, after approval by the commission and in accordance with the provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, such rules and regulations as may be reasonable and proper to carry out the purposes and intent of this division and to enable the authority to exercise the powers and perform the duties conferred upon it by this division not inconsistent with any of the provisions of any statute of this state.


Statewide coordination is accomplished through the participation of an eighteen (18) member Commission on EMS as identified in Health and Safety Code 1799.12 Their role is to “review and approve regulations, standards, and guidelines to be developed by the authority for implementation of this division.” What is the role of a local EMS agency? Local EMS agencies (LEMSA) are required, by Health and Safety Code Section 1797.204 to plan, implement, and evaluate an emergency medical services system, consisting of an organized pattern of readiness and response services based on public and private agreements and operational procedures. The importance of 1797.204 is made abundantly clear in the San Bernardino decision as the court articulated in multiple references that one of the key provisions of the entire EMS act is 1797.204.

1797.204. The local EMS agency shall plan, implement, and evaluate an emergency medical services system, in accordance with the provisions of this part, consisting of an organized pattern of readiness and response services based on public and private agreements and operational procedures.

The court in San Bernardino noted that one of the key provisions of the act is section 1797.204, which requires the local EMS agency to “plan, implement, and evaluate an emergency medical services system, in accordance with the provisions of this part, consisting of an organized pattern of readiness and response services based on public and private agreements and operational procedures.”13

It should be noted that the legislative intent of 1797.204 is for both the LEMSA and cities to work cooperatively to provide quality care for patients, and typically agreements are the mechanism to ensure all parties are aware of, understand, and agree to comply with, local policies. The section indicates the need for public and private agreements which are reflected in the California Code of Regulations (CCR) Section 100167(b)(4). What is the role of medical control? One of the overarching concepts in the regulatory scheme is the requirement for medical direction and medical control of the EMS system. Two statutes are important in this construct.


1798. (a) The medical direction and management of an emergency medical services system shall be under the medical control of the medical director of the local EMS agency. This medical control shall be maintained in accordance with standards for medical control established by the authority. (b) Medical control shall be within an EMS system which complies with the minimum standards adopted by the authority, and which is established and implemented by the local EMS agency. (c) In the event a medical director of a base station questions the medical effect of a policy of a local EMS agency, the medical director of the base station shall submit a written statement to the medical director of the local EMS agency requesting a review by a panel of medical directors of other base stations. Upon receipt of the request, the medical director of a local EMS agency shall promptly convene a panel of medical directors of base stations to evaluate the written statement. The panel shall be composed of all the medical directors of the base stations in the region, except that the local EMS medical director may limit the panel to five members. This subdivision shall remain in effect only until the authority adopts more comprehensive regulations that supersede this subdivision. [Amended by SB 1124 (CH 1391) 1984.

1797.220. The local EMS agency, using state minimum standards, shall establish policies and procedures approved by the medical director of the local EMS agency to assure medical control of the EMS system. The policies and procedures approved by the medical director may require basic life support emergency medical transportation services to meet any medical control requirements including dispatch, patient destination policies, patient care guidelines, and quality assurance requirements. [Amended by AB 3269 (CH 1390) 1988.]

Health and Safety code 1797.220 addresses issues related to medical control. The local EMS agency is required to develop policies and procedures that are approved by the medical director. These policies and procedures may require basic life support emergency medical transportation services to meet any medical control requirements including dispatch, patient destination policies, patient care guidelines, and quality assurance requirements. It is important to note that 1797.204 and 1797.220 do not address the same topics. 1797.204 states that the local EMS agency has the responsibility to plan, implement, and evaluate the EMS system while 1797.220 addresses items related to policy and procedure aspects of the EMS system. The court here also noted that “the term ‘medical control’ was not intended to be confined strictly to such higher level policy matters as the establishment of certification standards and training programs for paramedics, or emergency treatment procedures implemented by base hospitals.”14


What are the roles of EMS providers? The roles of providers of EMS services, both public and private, are a critical part of the EMS infrastructure. Both public and private EMS providers respond to emergency and non-emergency requests for medical assistance and transportation. However, they are not regulatory bodies within the context of a coordinated and integrated EMS system. As part of the EMS planning effort, all providers should be incorporated in the planning process to ensure meaningful participation in the local EMS system. This will enable a greater degree of coordination and integration to ensure that an effective and efficient EMS system can be achieved consistent with the goals of the EMS Act. Local EMS agencies employ a variety of methodologies to provide for meaningful participation in an EMS system. One mechanism is the use of a local Emergency Medical Care Committee or similar participatory structure. The requirement for a local Emergency Medical Care Committee was eliminated in 1993 as part of a reduction in County mandates. However, a local Emergency Medical Care Committee may be established to ensure meaningful participation in the local EMS system planning process. The following statutes, beginning with Health and Safety code 1797.270, are often used by local EMS agencies to assist in local EMS planning:

1797.270. An emergency medical care committee may be established in each county in this state. Nothing in this division should be construed to prevent two or more adjacent counties from establishing a single committee for review of emergency medical care in these counties. [Formerly H & S Code Section 1751. Amended by SB 627 (CH 64) 1993.] 1797.272. The county board of supervisors shall prescribe the membership, and appoint the members, of the emergency medical care committee. If two or more adjacent counties establish a committee, the county boards of supervisors shall jointly prescribe the membership, and appoint the members of the committee. [Formerly H & S Code Section 1752.] 1797.274. The emergency medical care committee shall, at least annually, review the operations of each of the following: (a) Ambulance services operating within the county. (b) Emergency medical care offered within the county, including programs for training large numbers of people in cardiopulmonary resuscitation and lifesaving first aid techniques. (c) First aid practices in the county. [Formerly H & S Code Section 1755.]

1797.276. Every emergency medical care committee shall, at least annually, report to the authority, and the local EMS agency its observations and recommendations relative to its review of the ambulance services, emergency medical care, and first aid practices, and programs for training people in cardiopulmonary resuscitation and lifesaving first aid techniques, and public participation in such programs in that county. The emergency medical care committee shall submit its observations and recommendations to the county board or boards of supervisors which it serves and shall act in an advisory capacity to the county board or boards of supervisors which it serves, and to the local EMS agency, on all matters relating to emergency medical services as directed by the board or boards of supervisors. [Formerly H & S Code Section 1756. Amended by AB 1119 (CH 260) 1988.]

Although Health and Safety Code 1797.270 was amended in 1993 to be an optional provision, consideration should be given to requiring formation of a local Emergency Medical systems committee as part of the local planning process to ensure meaningful participation by EMS system participants.



SECTON III:

HEALTH AND SAFETY CODE 1797.201 – WHAT DOES IT MEAN in 2010? Almost 30 years after the implementation of the statute, the issue of the rights or obligations of cities or fire districts under section 1797.201 seems moot given the widespread integration of EMS services throughout California. Those services that had ALS, LALS, or ambulance services in 1980, and wished to continue them, have generally retained that type of service. The San Bernardino decision notes “As we have seen, the EMS Act aims to achieve integration and coordination among various government agencies and EMS providers, and the Legislature likely contemplated that 1797.201 cities and fire districts would eventually be integrated into local EMS agencies.” 15 Health and Safety Code Section 1797.201 reads:

1797.201. Upon the request of a city or fire district that contracted for or provided, as of June 1, 1980, prehospital emergency medical services, a county shall enter into a written agreement with the city or fire district regarding the provision of prehospital emergency medical services for that city or fire district. Until such time that an agreement is reached, prehospital emergency medical services shall be continued at not less than the existing level, and the administration of prehospital EMS by cities and fire districts presently providing such services shall be retained by those cities and fire districts, except the level of prehospital EMS may be reduced where the city council, or the governing body of a fire district, pursuant to a public hearing, determines that the reduction is necessary. Notwithstanding any provision of this section the provisions of Chapter 5 (commencing with Section 1798) shall apply.

Is HS 1797.201 the symptom or the cause of conflict? The court in San Bernardino observed that “Only when a county or local EMS agency attempts to assert its authority in a manner that is contrary to the perceived interests of cities and fire districts would these latter agencies have the occasion to decide whether they wish to formally assert against a county their section 1797.201 rights.”16

The statutes do not specify exactly what a .201 city or fire district is. Moreover, it does not provide a separate agency or body to determine if a city or fire district has those specific rights. As a result, the only way to adjudicate any disagreements is through the courts.


Section 1797.201 allows existing cities and fire districts that provided care prior to June 1, 1980, to continue services and retain administration of those prehospital services under very specific parameters until formal integration through an agreement between the city or fire district and a local emergency medical services agency (LEMSA) occurs. H&S Code Section 1797.201 sets forth the specific obligation for cities and fire districts that meet the criteria in this section to continue providing service until such time as they requested to enter into a written agreement with the county. Importantly, the court in the San Bernardino decision noted that “…1797.201 is ‘transitional’ in the sense that there is a manifest legislative expectation that cities and counties will eventually come to an agreement with regard to the provision of emergency medical services …..” 17 The court here also noted a “pre-agreement period”. The pre-agreement period of 1797.201 requires that a city or county which performed prehospital emergency medical services as of June 1, 1980, to continue doing so until such time as an agreement is reached with the county. In the “post agreement period” of an implementation, the city or county is considered an integrated part of the local EMS system pursuant to the terms of the agreement. The San Bernardino decision states that “Nothing in this reference to 1797.201 suggests that cities or fire districts are to be allowed to expand their services, or to create their own exclusive operating areas.” 18 It is also recognized that until such time as an agreement is reached, the authorization for LALS or ALS as noted in 1797.178 is derived statutorily, provided medical control is maintained. Therefore, a written agreement cannot be compelled for those entities falling under the provision of 1797.201 that have yet to enter into an agreement with the county. The legislative intent for 1797.201 is clear that the “pre-agreement period” would be a temporary, transitional period of time. However, 30 years after the implementation of this section, there are cities and fire districts that have not entered into a written agreement to integrate into the local EMS system. The court noted that in the “pre-agreement period”, there is no provision that provides for any “grandfathering” of cities or fire districts in section 1797.201. Section 1797.201 does not grant exclusivity for ALS, LALS, or ambulance services. However, an eligible “1797.201” city may qualify for “grandfathering” under the provisions of 1797.224, if the criteria found there are fully met, subsequent to entering into a written agreement for integration and coordination into the local EMS system. EMSA has concerns that the use of the wording of “grandfathering” in relation to section 1797.201 entities is erroneous and potentially confusing. Section 1797.201 does not grant, by itself, any rights for grandfathering nor exclusivity. Additionally, the word “grandfathering” is not used anywhere in the EMS Act.


What exactly are the “rights and obligations” under section 1797.201? Consistent with the Apple Valley decision, EMSA believes that “.201 rights” should more properly be characterized as “.201 rights and obligations”. The rights and obligations under section .201 are that a city or fire district must provide prehospital EMS, during the transitional period of time before an agreement to integrate into the local EMS system is reached. The city or fire district’s “obligation” under 1797.201 is fairly limited. A city or fire district must maintain the level of service that was in place as of June 1, 1980, until an agreement for service is reached with the county. Alternatively, the services may be decreased after a public hearing. Unfortunately, section 1797.201 does not definitively specify any discrete right or set of rights. However, the courts have specifically clarified that two types of prehospital EMS services may be continued: Paramedic services and ambulance services. May a City or Fire District reclaim section 1797.201 rights? A common misperception seems to be that if a city or fire district had an agreement with a LEMSA at one time, and then that agreement was subsequently terminated, the city or fire district would then revert to the state of having their original .201 rights and obligations. This is not correct. The Court in Apple Valley concluded that section 1797.201 does not give a right of resumption to a city or fire district. Plainly stated, a city or fire district that has previously signed an agreement can no longer rely upon HS 1797.201, as it is no longer applicable. The court said that “Health & Saf. Code 1797.201, is not a broad recognition or authorization of autonomy in the administration of EMS for cities and fire districts. When a city or fire district ceases to be involved in the administration of some distinct part of EMS and allows the local EMS agency to assume that authority, it no longer has the prerogative to unilaterally resume control of that part of the EMS operation.”19

What is and who is a section 1797.201 City or Fire District? There are several criteria that must be examined when applying this provision. Previously, EMSA was requested to by Los Angeles County Fire Chiefs’ Association to ensure eligible .201 agencies receive a determination within the EMS plan.20 Buried in this request is the imperative for EMSA to either determine directly, or set criteria for the evaluation of, whether or not a city or fire district claiming that they are a “.201” entity meets specific requirements for that eligibility. Currently, there is no determination made as part of the EMS plan.


When considering the applicability of 1797.201 in relation to 1797.204, it is important to understand what constitutes an eligible “.201” city or fire district. Not all cities and fire districts are eligible entities. The specific 1797.201 eligibility criteria that a city or fire district must meet include, but are not limited to, all of the following:

• Be a City or Fire District that existed on June 1, 1980. • Be the same entity that existed on the date of the “1797.201” eligibility

evaluation. • Provided service on June 1, 1980, at one of these types: ALS, LALS, or

emergency ambulance services. • Operated, or directly contracted for the same type of service continuously since

June 1, 1980. • Has never entered into a written agreement with LEMSA for the type of service

they were providing in 1980, including ALS, LALS, or emergency ambulance services.

An eligible 1797.201 agency is entitled to retain, but not change (diminish or expand), their type of service. If they wish to change the type of service provided, an agreement must be entered into with the local EMS agency. After an agreement is reached with the local EMS agency (“post-agreement period”), the entity is considered “integrated and coordinated” into the local EMS system. Authorization for ALS under 1797.178 is then derived from the local EMS agency. After an agreement is reached, an agency may not reclaim “1797.201” pre-agreement status. Are agreements required? Under 1797.201, a county must enter into a written agreement with a city or fire district that requests an agreement with the county for the provision of EMS. With the transitional legislative intent of 1797.201, it is reasonable that a city or fire district that entered into an agreement for EMS after June 1, 1980, is said to have done so consistent with the language in 1797.201. Prior to the execution of any type of agreement between a city or fire district and a LEMSA, both parties should carefully consider the ramifications of entering into that agreement. Since section 1797.201 has been in place since June 1, 1980, local EMS agencies and city and fire districts should understand that an agreement would serve to fulfill the legislative intent to integrate into the EMS system. The EMS Authority does not see that there is, or has been, any incentive to deny or otherwise restrict a city or fire district from providing services it has provided since June 1, 1980, if no written agreement with the county has been entered into. As previously stated, 1797.201 is not a right but rather a responsibility of the city or fire district to continue providing EMS at the same level it did on June 1, 1980.


Is there a conflict between the EMS Act and the Regulations concerning the requirement for agreements? No conflict exists between existing statutes and the regulatory requirement for a written agreement, due to the nature of 1797.201 and the significance placed on the integration and coordination of EMS found in 1797.204. Although the San Bernardino decision makes clear that cities and fire districts must be integrated by agreement, there is no statutory deadline imposed for requesting or reaching such an agreement. The statute clearly intends that regardless whether or not an entity meets the requirements of H&S Section 1797.201 for the provision of EMS, the entity and the LEMSA must work together to formally coordinate the provision of medical control generally under Section 1798. California Code of Regulations, Title 22, Division 9, Chapter 4, Article 7, further defines medical control responsibilities of a LEMSA:

• Section 100167. Paramedic Service Provider: (b) an approved paramedic service provider shall: (4) Have a written agreement with the local EMS agency to participate in the EMS system and to comply with all applicable State regulations and local policies and procedures….

• Section 100169. Medical Control. The medical director of the local EMS agency shall establish and maintain control in the following manner: (a) Prospectively by assuring the development of written medical policies and procedures, to include at minimum: (1) Treatment protocols that encompass the paramedic scope of practice, (3) Criteria for initiating specified emergency medical treatments or standing orders for use in the event of communication failure… (4) Criteria for initiating specified emergency treatments prior to voice contact…

In EMSA’s previously expressed opinion regarding “Standing Field Treatment Protocols” (SFTP’s) in Los Angeles County, EMSA determined that SFTP’s are functionally a method to achieve “prospective” or “off-line” medical direction.21 Hence, provided an eligible “.201” agency complies with the medical control requirement, there is no reason that a formal written agreement be required in order to provide this patient-oriented care. In the event there is no formal written agreement, in order to achieve the medical control requirement, mechanisms for accountability and quality control must still be in place to ensure that EMS provider agencies adhere to all of the policies, procedures, medical controls and protocols of the Local EMS system.


Provided the entity is an eligible “.201” entity, the derivation of its authorization for advanced life support (ALS) is from H&S 1797.178 as a paramedic agency under the Wedworth-Townsend Paramedic Act. It is interesting to note that the Wedworth-Townsend Paramedic Act did not address limited advanced life support (LALS) [EMT-II], nor did it address emergency ambulance service. This gives further credence to the limiting nature of HS 1797.201.

1797.178. No person or organization shall provide advanced life support or limited advanced life support unless that person or organization is an authorized part of the emergency medical services system of the local EMS agency or of a pilot program operated pursuant to the Wedworth-Townsend Paramedic Act, Article 3 (commencing with Section 1480) of Chapter 2.5 of Division 2.

To remove the requirement for agreements from the Regulations would deviate from the legislative intent of 1797.204. However, EMSA will recognize that a LEMSA has met the minimum standards as part of their EMS plan, without written agreements, based upon the statutory authorization of an eligible “.201” agency. As noted earlier, an agreement between the LEMSA and a pre-agreement, eligible 1797.201 entity should meet the general criteria of intent to be integrated into and coordinated within an EMS system. In a previous interpretation from EMSA, the Authority stated that an agreement under Los Angeles County’s SFTP Program with the cities posited that it would “not affect the rights of a H&S Section 1797.201 city”. The concern of the cities is that the renewal of the same agreement would jeopardize their “1797.201” eligibility. Whether or not signing a narrowly worded SFTP agreement that solely impacts medical control actually affects H&S Section 1797.201 rights and responsibilities, is beyond the scope of this document. Can a LEMSA withdraw paramedic authorization unilaterally from a City or Fire District after an agreement has been signed? Although this has not been specifically addressed in the courts or in statute, it seems logical that once an agreement is signed, that city or fire district may continue to provide those paramedic services as set forth in the agreement. Although medical control is still required, withdrawal of paramedic services by the local EMS agency should only be done for significant cause and with due process. Additionally, unless the provisions of exclusivity as defined under Section 1797.85 and 1797.224 have been followed, the restriction of those types of services may not be possible.

EMSA encourages all parties to move forward and work collaboratively for the development of an integrated and coordinated EMS system. EMSA has concerns that a general call for refusal to sign any agreement, unless it preserves ambiguous 1797.201 rights, will only serve to prolong a non-productive discussion. Because the only mechanism to resolve a disagreement over 1797.201 rights or responsibilities lies in the courts, it is predictable that some situations will escalate to a point where legal action is chosen as the method of dispute resolution. This observation is an important one when evaluating possible solutions to the problems. A potential solution could be through a review process as part of the approval of a local EMS plan by EMSA. EMSA still questions whether a written agreement can specifically exempt the provisions of 1797.201, while still receiving the same benefits or consideration afforded an agency that has formally integrated and coordinated its services within the EMS system. Additionally, a question exists if there is a threshold limit for “non-201” agreements, coupled with integrative behavior, before it appears manifest that an eligible “1797.201” agency has “integrated” into the system.



SECTION IV:

PREHOSPITAL EMS--TYPE AND LEVEL OF SERVICE Prehospital emergency medical services, as used in HS 1797.201 in 1980, contemplated two types of discrete and severable service levels that were able to be continued at not less than the existing level: Paramedic services and ambulance services. What is the difference between level and type of service? EMSA notes clarification from the courts regarding the types and levels of service. The Petaluma decision, reinforced and clarified later by the Supreme Court in the San Bernardino decision, identifies that levels of services refer “to such matters as the quantity of available staff, vehicles, equipment, etc.”, and types of service “as constituting basic, advanced, or limited advanced life support”.22 The court in San Bernardino also clearly added ambulance services as a type of emergency medical services. The Petaluma decision defined the “types” of emergency medical services as “BLS, LALS, (and) ALS”, rather than as levels. Basic Life Support (BLS) is a statutorily defined term; there is nothing in the San Bernardino decision that further defines it. The use of “first responder” or “advanced first aid” as either a level or a type of service is also not found in the court’s opinion. Therefore, in this instance of evaluating 1797.201, BLS was likely seen as a type of service rather than a level of service. However, the provision of BLS is also not limited in statute, which means that anyone can provide it, and it is reasonable to believe that any provider can increase the training of their personnel within the general area of BLS. Consequently, it is unlikely that the continuation of BLS as a type of service was specifically contemplated in 1797.201. In the case of a 1797.201 city or fire district that was providing BLS (in some form) in 1980, moving from a BLS type of service to another type of service (i.e. ALS, LALS, or emergency ambulance service) would not be permitted without authorization from the local EMS agency. Reconciling this construct, it is reasonable to also consider prehospital EMS types as “ALS, LALS, and emergency ambulance services” as being consistent with H&S 1797.85. In this example, ALS and LALS may be provided by non-transport services. This allows for consistency with the “grandfathering” provisions contemplated in 1797.224. As both 1797.85 and 1797.224 were chaptered after 1797.201, it provides a clear mechanism for integration of the system and receiving the benefits of that coordination and integration under a written agreement.


The San Bernardino decision confirms this interpretation, “Thus, construing section 1797.201 in light of section 1797.224 and the system of EOA’s that it envisions, we conclude section 1797.201 was designed to confine EMS operations by cities and fire districts to those types in which they were historically engaged as of June 1, 1980.” 23 Additionally, any position that levels of prehospital emergency medical services include first responder, advanced first aid, BLS, LALS, or ALS, cannot be found or confirmed anywhere in statute or within the intent of the EMS Act. This interpretation would allow an eligible section 1797.201 entity to freely move through these levels at its own discretion, and neither the San Bernardino nor Apple Valley decisions support this. What are the different types of exclusivity? There is a distinct difference between type and level of service (or scope of operations) when considering ambulance zone exclusivity. “Type of service” refers to specified characteristics that distinguish a provider, while “level of service” refers to a provider’s relative position in terms of the quantity or scope of services provided. “Type of service” is expressly related to exclusive operating areas under 1797.85 and is not referenced in 1797.201. When reconciling these terms, it is apparent that the types of service that may be created as exclusive types are defined in 1797.85 and are limited to the following:

• Emergency Ambulance Services • Advanced Life Support • Limited Advanced Life Support

Is dispatch a type of prehospital EMS that was contemplated as part of HS 1797.201? Dispatch of emergency medical services units continues to be a topic of discussion, especially as it relates to who may perform the dispatch of EMS providers. The question is; “when does medical control and oversight begin in relation to a call for medical assistance?” From a historical perspective, emergency medical dispatch was not present in the United States until around 1979.24 Additionally, it was not adopted widely in California until the mid to late 1980s after EMSA published EMD training guidelines in 1986. It is therefore unlikely that dispatch was contemplated at a type of service under 1797.201. The San Bernardino decision rejected dispatch as a type of prehospital EMS service contemplated under section 1797.201. The provision of dispatch services is not a “type of service”, but rather a “coordination function” under medical control. Medical control in section 1797.220 is a function of the medical director of the local EMS agency to assure medical oversight of the EMS system.

The San Bernardino decision states that the EMS act views dispatch as a coordination function of the local EMS agencies that have medical control related to “affecting the speed and effectiveness of the response to medical emergencies”.25 The Court further identified that the dispatch as part of administrative control in section 1797.201 only referred to “internal” dispatch policies for that city or fire district. Although dispatch could be seen as a non-severable part of the “internal” dispatch of a type of apparatus, it would still be dependent upon the type of service provided by a 1797.201 city or fire district in 1980--either ambulance service or paramedic services. Unfortunately, this would answer neither the fundamental question of who gets dispatched “first” nor the question of who decides where emergency medical dispatch occurs. The court in San Bernardino noted that the dispatch protocol is also confirmed by section 1797.220, and by the overriding purpose of the EMS Act to afford some measure of coordination and [929*] integration to the provision of emergency medical services.” The court held that the “City is obliged, under section 1797.201, to follow them.”26

A 2003 Attorney General opinion concluded also that “Emergency medical dispatch services are subject to the review and approval of the local emergency medical services agency even when the services are developed, implemented, and operated in accordance with state guidelines.”27

The EMS Authority considers dispatch to be a part of the EMS system, and therefore it falls within the control of the local EMS agency to plan, implement and evaluate that aspect of EMS under HS 1797.204. The application of dispatch to EMS is not singularly a city or fire district’s internal administrative function, but rather it is a part of the overall EMS system and is included in the required coordination and integration to ensure medical control of the system.



SECTION V:

AMBULANCE ZONE EXCLUSIVITY The creation of exclusive operating areas is expressly permitted in Health and Safety Code 1797.6, 1797.85, and 1797.224.28 These statutes continue the “two-tiered” local and State regulatory scheme. The court in San Bernardino noted that “a local EMS agency may create one or more exclusive operating areas in the development of a local [EMS] plan . . . . “29

1797.6. (a) It is the policy of the State of California to ensure the provision of effective and efficient emergency medical care. The Legislature finds and declares that achieving this policy has been hindered by the confusion and concern in the 58 counties resulting from the United States Supreme Court's holding in Community Communications Company, Inc. v. City of Boulder, Colorado, 455 U.S. 40, 70 L. Ed.2d810, 102 S. Ct. 835, regarding local governmental liability under federal antitrust laws. (b) It is the intent of the Legislature in enacting this section and Sections 1797.85 and 1797.224 to prescribe and exercise the degree of state direction and supervision over emergency medical services as will provide for state action immunity under federal antitrust laws for activities undertaken by local governmental entities in carrying out their prescribed functions under this division. [Added by AB 3153 (CH 1349) 1984.] 1797.85. "Exclusive operating area" means an EMS area or subarea defined by the emergency medical services plan for which a local EMS agency, upon the recommendation of a county, restricts operations to one or more emergency ambulance services or providers of limited advanced life support or advanced life support. [Added by AB 3153 (CH 1349) 1984.] 1797.224. A local EMS agency may create one or more exclusive operating areas in the development of a local plan, if a competitive process is utilized to select the provider or providers of the services pursuant to the plan. No competitive process is required if the local EMS agency develops or implements a local plan that continues the use of existing providers operating within a local EMS area in the manner and scope in which the services have been provided without interruption since January 1, 1981. A local EMS agency which elects to create one or more exclusive operating areas in the development of a local plan shall develop and submit for approval to the authority, as part of the local EMS plan, its competitive process for selecting providers and determining the scope of their operations. This plan shall include provisions for a competitive process held at periodic intervals. Nothing in this section supersedes Section 1797.201. [Added by AB 3153 (CH 1349) 1984.]


The court in San Bernardino noted that “The ability to create EOA’s recognized in section 1797.224 would be rendered largely futile, however, if cities or fire districts that had no history of operating ambulance services were able to at any time to expand into those services, thereby partially nullifying an existing EOA. Thus, construing section 1797.201 in light of section 1797.224 and the system of EOA’s that it envisions, we conclude that section 1797.201 was designed to confine EMS operations by cities and fire districts to those types in which they were historically engaged as of June 1, 1980.”30

The court also answers some important points:

• First, “the ability to create EOA’s in section 1797.224 is made expressly subject to 1797.201 and therefore would not permit a county or EMS agency to unilaterally displace a city or fire district continuing to operate emergency medical services.”31

• Second, “nothing in section 1797.224 prevents a local EMS agency from assigning an EOA within the borders of a city or fire district to a private provider, if the city or fire district ceases to offer a certain type of emergency medical service.”32

• Third, “nothing in either section 1797.201 or section 1797.224 suggests that once a city or fire district has abandoned emergency medical services and allowed another entity, pursuant to an EOA, to provide such services, it has the right to nullify the EOA by resuming control of these operations.”33

By extension of the second point above, a local EMS agency may assign non-exclusive status to an area, including a city or fire district that claims certain rights under 1797.201, if that area does not qualify for the continuation of exclusivity without a competitive process. Alternatively, a local EMS agency may identify that the area is non-exclusive until such time as an agreement is reached to continue the area under the provisions of section 1797.224, if that area qualifies for that continuation of exclusivity. Can a City or Fire District establish an EOA? The court in San Bernardino said that it is important to note that “section 1797.224 speaks only of local EMS agencies, not cities or fire districts, creating an emergency operating area (EOA).” 34 If an eligible 1797.201 City or Fire District is providing ambulance services, does that automatically make the ambulance zone exclusive?


Section 1797.201 does not grant exclusivity for emergency ambulance, advanced life support or limited advanced life support services. An eligible 1797.201 city or fire district may quality for exclusivity without a competitive process, if the criteria in 1797.224 are fully met after entering into an agreement for integration and coordination into the local EMS system. It is important to clarify that 1797.201 does not grant any rights for a city or fire district to ambulance zone exclusivity without a competitive process. 1797.201 only provides for the right to service the boundaries of that city or fire district, as clarified in the Petaluma decision.35

Can an eligible 1797.201 City or Fire District have their ambulance zone become exclusive without a competitive process? The court noted that “Section 1797.224 makes clear that a city or fire district that has provided emergency medical services ‘without interruption since January 1, 1981,’ can be assigned exclusive operating areas without going through a competitive bidding process.”36

A provider agency may be “grandfathered” into an exclusive operating area if qualified in concordance with 1797.224, if there was no change in the manner and scope, after a written agreement with the local EMS agency is secured. Are there financial incentives involved in the creation of exclusive operating areas? As part of the responsibility for indigent care under California Welfare and Institutions code section 17000, a county has a responsibility to ensure that services are available and payment is made to ensure critical services as a “payer of last resort”. In the “Lomita I” decision the court noted that it is the “statutory duty of a County to provide hospital and medical services to all indigent County residents. (County of San Diego v. Viloria, 276 Cal.App.2d 350, 352--353 [80 Cal.Rptr. 869 (1969). When an emergency occurs anywhere in the county which requires hospitalization, it necessarily follows that the duty to provide medical care includes the duty to provide emergency transportation from the place where the indigent is to the hospital where he can receive care. The cost of providing that service is, by statute, a proper county charge (Gov. Code, § 29606; Health & Saf. Code, § 1444.).”37

As it relates to ambulance services, the “Lomita II” decision confirmed that the county had financial responsibility.38 The county, or its local EMS agency, may organize the EMS system with this responsibility in mind. It specifically gave four options for the County:

“The county's duty to such persons may be fulfilled in any one of four different ways or by any combination of such services. (1) The county may create a separate county department to provide emergency ambulance service, equipping such department with the necessary vehicles and other equipment, as well as personnel in such department and pay the expenses of operating such department as it staffs and operates other county departments. (2) It may assign the duty of providing emergency ambulance service to residents of the county to such existing county department as it may choose and provide that department with the necessary equipment and trained personnel. [*482] (3) It may contract with the cities or local agencies located within the county to provide necessary emergency ambulance service to the residents of the county found within such city or cities; or, (4) It may contract with private ambulance companies.”

These options remain at the discretion of the county to fulfill their financial obligation.

With respect to ambulance service exclusivity, a City or Fire District cannot claim to both hold 1797.201 rights, and also simultaneously receive the benefits of exclusivity under 1797.224, as an integrated part of an EMS system.



SECTION VI:

OBSERVATIONS AND CONSIDERATIONS

What are EMSA’s observations? Coordination and integration of the EMS System is the primary goal for emergency medical services in California. This system coordination is achieved by a “two tiered” system of regulation at the State and local EMS agency levels. Within this structure, medical control is broad and must be maintained. The methodology to achieve an effective and efficient system is through the use of agreements to achieve EMS system coordination. Both public and private EMS providers should be engaged as part of a local planning process to ensure meaningful involvement by all system participants. The goal of the legislature when considering EMS systems was for cities and fire districts to be integrated into an organized EMS system and to sign agreements. Section 1797.201 was seen as a transitional part of the EMS Act. Unfortunately, there is no required date to enter into agreements under 1797.201. Consequently, section 1797.201 is being cited as authority for a city or fire district to remain free from local EMS agency oversight. At this time, it is unclear what discrete 1797.201 rights exist, if any, beyond the provision of paramedic services and emergency ambulance services. However, the predominant issue under discussion is the provision of dispatch of emergency medical assets and whether that is included as a right under in section 1797.201. There is presently no independent authority for review and verification of what constitutes a section 1797.201 city or fire district. This means that every disagreement has the potential to be resolved through the court system. Although in many cases agreements in various forms have been entered into, there is now some disagreement as to what specific terms an agreement must contain and the form it may take. The courts seem to be clear that a city or fire district may not avail itself of the use of 1797.201 after an agreement has been reached, if there is an interruption of service, or upon the termination of an existing agreement. At its time of inception, it seems clear that section 1797.201 only contemplated two (2) types of service for continuation—paramedic service and emergency ambulance service. Dispatch was not a prehospital EMS service or type under 1797.201, especially since emergency medical dispatch was not widely known at the time the law was written. Under section 1797.201, cities and fire districts are required to maintain services at not less than the level they were providing it in 1980. They may adjust the level of service upward in the areas of quantity of available staff, vehicles, equipment, etc. but a city or fire district may not enter into new types of services.


Ambulance services provided by cities or fire districts do not obtain exclusivity from section 1797.201. However, ambulance services may be grandfathered under section 1797.224 if they qualify and are part of the local EMS system through an agreement. What are some considerations for resolution? Three specific recommendations are identified for discussion as part of this document. The following considerations reflect some limited solutions to the ongoing discussion related to the application of section 1797.201 in light of the overarching legislative intent to have a coordinated and integrated EMS system in 2010: 1. Agreements should be reached between a local EMS agency and an eligible city or fire district under 1797.201, for those areas that have not already done so, that specify and clearly articulate the type of service and role in the EMS system. 2. Local EMS plans should include a review and verification of what constitutes a section 1797.201 city or fire district, and what type of prehospital EMS service that entity provides, as part of an EMS plan that is submitted to EMSA for approval. 3. A local Emergency Medical Care Committee should be required at the local EMS level to ensure meaningful involvement by EMS system participants.


ENDNOTES

1 California Health and Safety Code, Division 2.5, Section 1797 et seq. Initially passed as SB 125 (Statutes of 1980).

2 California Code of Regulations, Title 22, Division 9.

3 County of San Bernardino v. City of San Bernardino, 15 Cal. 4th 909 (1997)

4 Valley Medical Transport v. Apple Valley Fire Protection District, 17 Cal.4th 747 (1998)

5 City of Petaluma v. County of Sonoma, 12 Cal. App.4th 1239 (1993).

6 Apple Valley at 754.


8 County of San Bernardino at 927.

9 Wedworth‐Townsend Pilot Paramedic Act, SB 772 (Statutes of 1970).

10 Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act (EMS Act), SB 125 (Statutes of 1980).

11 California Health and Safety Code 1797.101.

12 California Health and Safety Code 1799.








20 Letter to EMSA from Jim Hone, Los Angeles Area Fire Chiefs’ Association, dated April 8, 2008.

21 Letter to Jim Hone Los Angeles Area Fire Chiefs’ Association, and Cathy Chidester, Los Angeles County EMS Agency, from EMSA dated October 23, 2008.




24 Clawson J. and Dernocoeur K. Principles of Emergency Medical Dispatch. Englewood Cliffs, New Jersey: Brady/Prentice Hall (1988).


26 Valley Medical Transport v. Apple Valley Fire Protection District, 17 Cal.4th 747 (1998).

27 Bill Lockyer, Attorney General Opinion No. 03‐316, September 5, 2003.

28 Added by AB 3153, Bronzan (Statutes of 1984).









37 City of Lomita v. County of Los Angeles, 148 Cal. App. 3d 671 (1983).

38 City of Lomita v. Superior Court of Los Angeles, County of Los Angeles, 186 Cal. App. 3d 479 (1986).

EXHIBIT B

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY ARNOLD SCHWARZENEGGER, Governor

EMERGENCY MEDICAL SERVICES AUTHORITY 1930 9th STREET SACRAMENTO, CA 95811-7043 (916) 322-4336 FAX (916) 324-2875

REDENED MAY b 9 ZOOS

CONTRA COSTA EMERGENCY MEDICAL SERVICES

DATE: May 15, 2008

TO: All Local Emergency Medical Services Administrators and Medical Directors

1A.LcaQ ; FROM: Daniel R. Smiley Chief Deputy Director

SUBJECT: 30-Day Review of Ambulance EOA Review Criteria and Zone Listing

The Emergency Medical Services Authority (EMSA) has prepared the attached two draft documents to provide clarification regarding transportation and exclusive operating areas as well as a listing of all the ambulance zone areas in California, as shown in our records. We have had numerous questions regarding these issues over the years and hope these documents will be helpful in your understanding of the ambulance zones and our review process. Drafts of the following documents are attached for your review and comment.

• "Review Criteria and Policy for Transportation and Exclusive Operating Area Components of the EMS Plan"- This is a compilation of review criteria and policy used by EMSA to review exclusive operating areas. Further, it incorporates the previous EMSA #141 which outlines the competitive process for creating exclusive operating areas.

• "California Emergency Ambulance Zones" -This is information compiled from the EMS plans. Please note that this reflects information as shown in the EMS plans and may not reflect any unresolved issues. Please review this document for accuracy and let us know if there is a discrepancy.

Please review these documents and give us your comments by June 21, 2008. If you have any questions, please contact Bonnie Sinz or Donna Nicolaus at (916) 322-4336 or e-mail: [email protected].

REVIEW CRITERIA AND POLICY FOR TRANSPORTATION

AND EXCLUSIVEOPERATING AREA COMPONENTS OF

THE. EMS PLAN

te9tom_ sefi,fr

ett kI l la — 7 C

O 2 Ce 0 EMSA #141 0 -?/ 2nd Edition April 2008 t 'Y 1st Edition February 1987

N)* sr

• eill./FORO ,

2

2

3

II. DEFINITIONS 4

III. TRANSPORTA-qt*P 7A I PROCL 1 G 6

A. The EM ansportatie 6

B. CMS, brt Ian R Approval 7

8

8

46* ranspdreaten Plandates te4

:Changes of EM Operattbg Area or Sub-area

IV. OPER ITING AREA 9

10

10

1. Criteria for Establishing an Exclusive Operating Area 11

2. Exclusivity of Designated Exclusive Operating Areas 12

3. Inter-facility Transports 12

C. Exclusivity via the "Grandfathering" Process 13

A. Non ExcluSiue,LJperating Areas

B. Exclusive ()berating Areas

TABLE OF CONTENTS

I. INTRODUCTION 1

A. EMS Transportation Review Policy - Introduction 1

B. EMS Authority Statutory Oversight of EMS Transport kin Systems 1

C. LEMSA Statutory Responsibility for EMS Trap ortarlpri Systems 2

D. EMS Transportation System Design. 2

E. Restriction of Trade for Transport,

1. Federal Law and Court Rulings

2. Local "Need and N

'MON

Review Criteria and Policy for Transportation and Exclusive Operating Area Components of the EMS Plan

California EMS Authority

1. Manner and Scope Evaluation Criteria 13

2. Health and Safety Code Section 1797.226 14

3. Health and Safety Code Section 1797.201 15

4. EMSA Withdrawal of Approval 15

D. Exclusivity via the Competitive Process 16

V. COMPETITIVE PROCESS - CREATING EXCLUSIVE OPERATING AREAS 19

A. Introduction 19

B. Formal Advertising: Invitations 19

C. Bidders' Conference 20 1 ix

D. Proposal Contents 20

E. Submission of Proposals 21

F. Receipt and Evaluation of Proposals-,;,, 22

G. Rejection of Proposals 23

H. Contract Pehods 24

I. Protest8 24

J. Canceling theProcurement Process after Opening 25

APPENDICES 26

AppendiXA — Ambulance ,Z ne SUMmary Form 27

Appendix B - Grandfathq ing Checklist (REVISED May 2007) 29

Appendix C - ApplieOle Health and Safety Code Sections 31

Appendix D - Relevant Sections of the Standards and Guidelines 34


California EMS Authority

I. INTRODUCTION

A. EMS Transportation Review Policy - Introduction

In 1980, the Emergency Medical Services (EMS) Act granted authority to the EMS Authority to provide oversight of the planning, implementation, and evaluation of Local Emergency Medical Services Agency (LEMSA) systems, including local transportation plans. Based on the requiwent contained in California Health and Safety Code Section 1797.103, EMS Authority developed the "EMS Systems Standards and Guidele (EMSA Publication #101).

.--;”. In 1984, prompted by the decision in CommatiCommuniCations Co Inc v

provided State authorization and oversigitt th City of Boulder (1982), 455 U.S. 40, Californiaos eneaccrteeadtiAonB 03;f1(pronzan). This

011,s1,ye- operating.areas by LEMSAs. Health and Safety Code f Section 1,797.6 states the;Legislature's intent to delineate the deolekp State ,,,, direction and oversight required to extend state immunity to LEWIS: tr'ecific emergency medical services, as defined in sections 1,797.6, 170 CCaand 1797.224 of the Health and Safety Code (see Appendixt)s ..' .

Since the transportation plan is an intrica e portion ofthe EMS Plan, the EMS Authority has developed the "Rey' igefwCriteria anAipplicy for Transportation and Exclusive Operar 1-4,,,-,.

, ip Ait comporontpof the EMS Plan." This will provide technical assistance to 124SAs in developing and updating their EMS Transportati&:lans.,estalishing ari,irnplementing ambulance operating areas or zones, an't14761arif 00%:tulleerand;Salety Code sections relevant to EMS transportation.' Iiiiil in I ,sp.pfotes applicable standards from the "EMS Syste*StandarAid GuidelineelEIVISA Publication #101 — which can be round at http //wwwiernba . pubs. asp), qov/aboutemsa/emsa pubs asp), and the

mblication #141*competitive Process rokpia Creating Exclusive Operating Areas"(formerly EMSA

B. EMS uthority Staltory Oversight of EMS Transportation Systems

Health an, 'ode Section 1797.105 calls for a LEMSA to submit its EMS Plan (incluei Rstplhe transportation plan) to the EMS Authority for approval. The EMS Authority determines whether the EMS Plan effectively meets the needs of the affected communities, is consistent with existing guidelines and regulations, and adequately coordinates activities in the area served. In addition, Health and Safety Code Section 1797.102 requires the EMS Authority, utilizing local/regional information found in EMS Plans, to assess the EMS areas to determine the need for, coordination of, and effectiveness of emergency medical services. Therefore, the EMS Authority bears a responsibility to ensure that the local transportation system adequately serves the community.


California EMS Authority Page 1

C. LEMSA Statutory Responsibility for EMS Transportation Systems

Under Health and Safety Code section 1797.200, each county that develops an EMS program shall designate a LEMSA to administer emergency medical services. Section 1797.204 requires a LEMSA to plan, implement, and evaluate an emergency medical services system. Because transportation planning is an integral component of an EMS system, the LEMSAs are responsible for administering the transportation component of the EMS system and for ensuring this component is adequately coordinated with other system components; for example, trauma, disaster medical services, EMS for clifildeen, and communications. Section 1797.222 authorizes thecoUnties to adopt ordinances governing patient transport and also tasks the LEMSAs with recommending the adoption of such ordinances to the County Boardkpf SupeNtsors. This shared responsibility for developing local governance/refThe EMS transportation system requires local officials to work cooperatively te'ensure the design of the EMS transportation system adequately meetsithe needs of the community.

D. EMS Transportation System Design

To meet its mandate of coordinating the local S system, and to comply with the EMS Act, a LEMSA should. design the local EMS transportation system to ensure that all transport providers are integrated into. he EMS system. A LEMSA should ensure that it maintains contracts or operating agreements with all emergency transportproviders liCensed ,dyAhebalifornia Highway Patrol (CHP). In addition, a LEMSA should integSte;01Prion-erti erdency transport providers (gurney, wheelchair vanS'itOr other forts of medical transport) operating in its jurisdictiod.MJS task mayPp accomplished through a local ordinance or LEMSA policy defining requirements for transpOrt, (See Section Ill — "Transportation Plan Processing" for edditiok SprieSielpties).

or Transport Providers

Federal Law arid Court Rulings

Federal law gpOrning restriction of trade is based on the Sherman Antitrust Act (1492),,add'the Clayton Act (1984). The Sherman Antitrust Act bans activitieSSat restrain trade, and bans any monopoly, or attempt to establish a monopoly, while the Clayton Act regulates practices that may inhibit fair competition, such as price discrimination, mergers, and acquisitions.

Certain regulatory activities may run counter to these laws; for example, a rural county may elect to establish an exclusive operating area (EOA) for ambulance service because it has been determined that the community may not otherwise have access to timely and reliable care. In such cases, federal courts have determined that anticompetitive regulatory programs may receive immunity from prosecution or legal action under state law



(Parker v. Brown 317 U.S. 341, 87 L. Ed. 315, 63 S. Ct. 307 [1943]). Nevertheless, court decisions since the 1980s, beginning with the federal "Boulder Decision" (Community Communications Co. Inc. v. City of Boulder, Colorado, et al [102 S. Ct. 835]), have limited the application of such "state action immunity" to local governments. Based upon the Boulder Decision, cities and counties are exempt for activities that are specifically authorized by the state and that are subject to state oversight.

2. Local "Need and Necessity" Ordinances

Prior to the EMS Act, counties in California y ittdneed and necessity" ordinances to restrict competition among poder8 prevent new providers from entering the market. Tbes ordinance ced the burden on potential providers to prove that thei,,, Sces were nedery to the community.

The rendering of the Boulder DeoisjOilbpnd the passage of the EMS Act, in addition to subsequent decisions of041, K-courts (e.g., Schaefer's Ambulance Service v County of San Bernardino, 80 Cal.Rptr.2d 385 [1998]), have superseda-1' tyr "need and n Oe‘ssity" ordinances established by the county. The onlytist b restrict competition in the ambulance marketplace is through adherence to provisions of the EMS Act/Health and Safety C,„

Relevap s ate and feral cot t ases may be reviewed on the ambulance page- One EMS Atrity's

sir,;1/4„ site:

viemsdivisionlambInc.asp)



II. DEFINITIONS

Advanced Life Support (ALS): Definitive pre-hospital emergency medical care performed by authorized personnel who possess a valid certificate, including but not limited to treatments as defined in Health and Safety Code Section 1797.52.

Basic Life Support (BLS): Emergency first aid and cardippKmonary resuscitation (CPR) procedures used to maintain life without invasiveibAhhiques and performed by an EMT I trained in all facets as defined in Health and fS;Ofety Code Section 1797.60 and possess a valid certificate.

Boundary Changes: Any reconfiguration of thetgeographic bbrders previously designated by the LEMSA for each operatingSb.

Competitive Process: The method by WfilCh a LEMSA,may award arrbrpbulance operating area exclusively to one or more PrbvIbers,45,y-brteating a RequeSt for Proposal and establishing a contract with the'Seied&Fbidder(s).

Critical Care Transport (CCT):laterLfacility transfer of a critically injured or ill person by an emergency ambulance, ete:iteyetof service of a registered nurse who is functioning pursuant to Section 2725 of tiiiM4"19.9,ss and Professions Code and who is following the standing orders of aheArebtiridphYsician.

Emergency Medical ServicksJEMS):1 services utilized in responding to a medical emergerty (Health and Safety Code Section 1797.72). This is inclusive of any ambulance service licbb04,4ytt9pali rnia Highway Patrol, irrespective of the levels ofpersonnel:1..e, Basic Lifeggpoirt-:(EtLS), Limited Advanced Life Support (LALS), Advanced Life Support (ALS), Registered Nurse (RN), Doctor of Medicine (MD)","Or call typeSAe. cot e3, Inter-facility Transport (IFT), Critical Care Transport (CCT), or care provided at thescene, i.e. ALS, BLS.

Excluaive Operating Area (EOA): An EMS area or sub-area defined by the emergency medical services plan for which a local EMS agency, upon the recommendation of ae66nty, restricts operations to one or more emergency ambulance services or P' roviders of limited advanced life support or advanced life support" (HealifieSafety Code Section 1797.85).

Grandfathering: A commonly used term that refers to creating an exclusive operating area from a non-exclusive operating area. This is restricted by statute to an area that continues to use an existing provider that has been in continuous operations within a local EMS area in the same manner and scope without interruption since January 1, 1981 (Health and Safety Code Section 1797.224).



Level of Exclusivity: Scope of the operation defined by the EMS Plan to restrict competition of area or sub-area to include, but not limited to: 9-1-1, all emergency, 9-1-1 and 7 digits, all emergency services, including inter-facility, and air ambulance.

Limited Advanced Life Support (LALS): Special service designed to provide pre-hospital emergency medical care limited to techniques and procedures that exceed BLS but are less than ALS and are those procedures specified to Section 1797.171. (Health and Safety Code Section 1797.92),

Local EMS Operating Area: A geographic area or subt: reg designated with ' boundaries, established by a LEMSA to facilitate sy;te rdination with providers. (Health and Safety Code Section 1797.85).

Non-Exclusive Operating Area: The EMS r F or sub-areae do not have restricted operations and are open to all wal ed providers approvedby a LEMSA.

st re-address `cliiiders and determining the

e greater than a 10 year

Periodic Interval: The timeframe in which E competitive process previously utilized for set scope of their operations. This timeframe shall

''provision, including any extensioW'

Manner and Scope: 'The economic digtri area or sub-area. Minter, and )nclL to the EMS operatinga sub-areteit irtt 0% the marketplace ,

Type of ExcluS in Health and Safe ALS.

e`rtaetplace within an EMS Stipration of geographic changes

euption &Services, free entry and exit in

erationsVithin an EMS area or sub-area as defined k:femergency ambulance services, LALS,

Review Criteria and Policy for Transportation and Exclusive Operating Area Components, of the EMS Plan


III.TRANSPORTATION PLAN PROCESSING

A. The EMS Transportation Plan

A LEMSA must develop a plan for the local EMS transportation system to comply with its mandate for planning and implementing the local EMS system, and to ensure that it conducts activities related to transportation with a sufficient degree of state direction and oversight. The EMS Transportatiopelan is an important component of the local EMS Plan and should provide, development, coordination, and oversight of transport by providers4with'n the geographic area that a LEMSA oversees. The Transportation Plerc,104be endorsed by the County Board of Supervisors or the LEMSA governing bbattl,prior to submission. The plan can be included as a separate chapter within a LEt%'s annual EMS Plan update or, if changes have occurred; the transportatft system after the last approval by the Authority, it ist e submitted separatelii4bfi an update.

The EMS Transportation Plan should incorporate the following elements:

• Table of contents

• A plan summary highlighting major-Sections of the plan, any changes since the Prqt:sso ibtssion, 40(gny key problems and proposed,sojytions. ;f f,

• Description Cr chart of the:,,Syitem structure and design. The deSCriPtion shodid address whether a LEMSA has established exclusive operating areas bririon-exclusive areas.

o CleAKipt n oals a ectiVei, an implementation schedule, and acted outcomes.

• AhajYsts of the fiscal impact of the transportation system design to the system (e. eciuest for Proposal (RFP) costs for a competitive processkrsulti l'avings from changing status of an area, costs for provider monitoring, etc.).

Inclusion of a mechanism to ensure that all ambulance service ProviderS,ficensed by the CHP are fully integrated into the EMS system.` This objective can be accomplished through a county ordinance requiring licensing or LEMSA policy (include copy of model policy or ordinance as an appendix).

o Describe integration of non-ambulance medical transport services, if applicable.

• Description of the relationship of the transportation plan to the specific components of the EMS plan, such as trauma, communications and dispatch, disaster, EMS for children, etc. and how the system is integrated into the EMS system as a whole.



• Justification for establishing EOAs, if any, and how they serve the LEMSA's mission. The justification must include "Ambulance Zone Summary" forms and maps of sufficient detail to show the service areas.

• Description of plan for mutual aid and a list of mutual aid providers.

• Description of the quality improvement (QI) process specific to transportation issues.

• Description of system evaluation process an evaluation of the transportation system.

• Copy of RFP if a competitive process an appendix).

• Verification of provider eligibility and=unchanged arer and scope of an operating area under Health Safety Code Set, 1797.224 for areas that are grandfathere, (include as an appendix):

• Contracts for exclusive providers includ 'S an appendix)W

B. EMS Transportation Plan evr w and Appro.,*

The EMS Authority will coordinait submission of a completed annu approved for the4odirentlt.

To prevent 'delays in the OS AuthoriSs review and approval of the transportationAlan, a IAN ;$4,4st2auld ensure the plan is clear, correct, and complete in aectopawitiffitts guidelines. If the EMS Authority requests aldjtrqttinturmatigAlc assist in its assessment of the plan, a LEMSA should submit the required tion within 30 days of the request. If the EMS

uthority does/6tAenceiliNalne requested information in a timely manner, the proval of the delayed, or the plan may potentially expire. Failure submit annualP

plan mayptlsuant to Health and Safety Code Section 1797.254

maY";tecpardize the„tate action immunity. The EMS Authority will provide neceStrytechniqatt.assistance to a LEMSA should there be questions or concernregardri 4-the plan.

In the event tHat the EMS Authority does not approve a plan, it will supply a complete explanation to a LEMSA. A LEMSA will be allowed 60 days to submit a revised plan. If the EMS Authority does not approve the revisions, pursuant to Health and Safety Code section 1797.105, a LEMSA may appeal the decision to the Commission on EMS. The Commission shall make a determination within six months of the appeal. The Commission may sustain the determination of the Authority or overrule and permit local implementation of the plan. The decision of the Commission is final.

mary of periodic

p, conducted (include as

risportation plan with the te. The plan will only be



When the EMS Authority approves a plan, a LEMSA must implement the plan as written. If the Authority determines that a LEMSA has failed to implement its transportation plan as it was presented to the EMS Authority, approval will be withdrawn.

C. Transportation Plan Updates

Any changes to the transportation plan shall be submittedito the EMS Authority for review and approval 60 days prior to the proposedpkjImplementation. Changes that should be received within 60 days of thirdeCision include the following:

® Intent to issue an RFP.

o A new provider begins servicg? p a current provider terminates operations. ",c'':,„).;,

. ., • Modifications to manner and scope ofservice provided in an exclusive

,, .:,yoperating area, including:

f,,

D Geographic ,1/4

D Geographic bOndarie 'eat

D Scopre.0 operable, onAwsporting to transporting, ALS ergency ambdi 9-1-1 only, interfacility transport, etc.).

;;evel of pxplusivity.

cqiyitYPe

billing or subdividing areas).

er's ownershIptasset transfer or transfer of business).

conOrpic distribution of calls.

roviders (free entry and exit).

➢ Ifite'rruptidit n service.

Minor system changes, such as changes of address for providers, minor boundary c to accommodate the completion of a new roadway), changes in the manner and scope of service in non-exclusive operating areas, or status updates of transportation related Standards and Guidelines need not be submitted separately but should be submitted as part of a LEMSA's annual EMS Plan update.

D. Changes of EMS Operating Area or Sub-area

A LEMSA has the authority to change the status of an ambulance operating area, approved in the EMS Plan by:



• Creating a non-exclusive operating area from an exclusive operating area previously established through competitive process.

• Creating an exclusive operating area from a non-exclusive operating area through competitive process.

• Creating an exclusive operating area from a non-exclusive operating area through grandfathering, as long as the criteria from Health and Safety Code Section 1797.224 have been met4

EXCEPTION: A LEMSA may not create an exclusiv it has previously issued an RFP with the intention exclusive through competitive process.

a via "grandfathering" if blishing the area as

For changes to the status of an area, frort ta: -exclusive to exclusive or vice , versa, a LEMSA must submit the transportation plan update to thIEMS Authority for review and approval prior to impleiWtation andcrithin 60 daya±cippe decision. nipq ,,, .,

If the status of an area is being modified froths oh exclusive to exclusive, via "grandfathering" or competitive; process, a LEMSAcannot refuse to accept completed applications from qualifiedproviders wishing to provide transportation services to the area during theltpes LEIVISNs transportation plan has been reviewed and roved byte EI S,Authority,#roperating areas are non-exclusive and arLEMSAimaynot teic protectioaa inder state action immunity for anti-trust, activities.

tihtt The EMS Mithtt will he statusVftexclusivity on its website.

cilitate systertiVordatian in the geographic area(s) it oversees, a LEMSA maygact to create ambulance operating areas that are either: non-exclusive, open to all qualified providers; or exclusive, restricted to select providers. The areas shall betatatlishect based on optimal service provision and patient care, not geopoliticalb"o_> n aaes or traditional service areas.



A. Non-Exclusive Operating Areas

In instances where a LEMSA chooses to maintain non-exclusive ambulance areas that are open to all qualified providers, a LEMSA must still ensure that the providers that serve the area are fully integrated into the EMS system and adhere to all requirements. A LEMSA should establish contracts or operating agreements with all providers and should ensure that the/cells in non-exclusive areas are distributed equitably, whether through an eyerbtation or other method to achieve equal distribution of calls or consistent dispatch of the closest unit.

Non-exclusive operating areas must be delineated in the EMrransportation Plan in the same manner as exclusive operating areas. A LEMSA should address non-exclusive operating areas in its response to the releVent sections of the "EMS Systems Standards and Guidelines," complete an "AmbolOce Zone Summary Form" (Appendix A) for each“Ofgiese providers, and ensure/the providers are included in the resources directory i#the EMS Plan update.

B. Exclusive Operating Areas

In an effort to develop 1. system-wide coordination1i:end/predictable EMS response, a LEcr, m4create one more exclusive operating areas (EOAs) in the develop Ment of the EMS EOA will rstrict the number of providers, public and/or private, with0q.designated EMS area or sub-area to:

One or,mgr, ''eme ency ambulance services; or

rovidersOsALS; or

O

aVaptages for estlablishing'EOAs may include: predictable EMS response initiated, from emergent cy calls received through a central dispatch; reduction of LEMSA/S1,:costs; avoidance of conflict among providers jointly serving an area; an increase bl,WiclOCY of the provider by minimizing direct costs; and maximizing skill maintenance of certified personnel.

As outlined under Health and Safety Code, Section 1797.224, an EOA may be established when the EMS providers within those areas are either "Grandfathered" or selected through a "Competitive Process."



Criteria for Establishing an Exclusive Operating Area

A LEMSA may establish EOAs if ALL of the following conditions are met:

• A LEMSA utilizes a competitive process to select the providers, OR a LEMSA chooses to "grandfather" existing providers, that is, "continue the use of existing providers operating within hrfnanner and scope in which the services have been provided withdr interruption since January 1, 1981."

• A LEMSA has revised its EMS Tra , sportation ̀ Pl„„„.to incorporate EOAs into its system and receiveapproval of thebisions from the

• A LEMSA has established ' and procedures to eri lie that the

,), EMS Authority prior to imple

transportation system complies the*alth and SafetVtode, the EMS Systems Standards and Gmlir and this document. Nothing precludes a LEMSAfrom adopbtiing1;16, 6'dyards for providers that are more stringent thafi sesta is EMS Authority. The policies should, at minimum, address the\oowi

Marketing➢ and V rtis providers. ,;A:r ,51/4e

, ocee used to di'bi riate excludive providers.

Establishment of service areas for providers.

Dispa~t hang inclludingUse of EMD.

munication

oordination with exclusive and non-exclusive providers.

ualk

including those for application, monitoring, and evathation.

4, ical control and accountability.

ata collection and management.

Y•" Quality control and system evaluation.

• Rates.

> Parameters of a call to avoid confusion over call origin and call continuation (e.g., for inter-county or inter-area calls, inter-facility transports, etc.).



2. Exclusivity of Designated Exclusive Operating Areas

If a LEMSA chooses to establish EOAs that are restricted to designated providers, it must do so in accordance with Health and Safety Code Sections 1797.85 and 1797.224. These sections allow LEMSAs to restrict operations to three types of exclusivity:

• Emergency ambulance.

• Providers of advanced life support (ALS).

• Providers of limited advanced life suppo LS).

A LEMSA can further restrict the scopeibtreratib :bf the transports to the following levels of exclusivity of services:

• Emergency ground ambulance (9-1-1 only).

tbk,. • Emergency ground ambulance (9-1-1.Aft 7 digit numbers).

• All emergency ground ambulance,(this includes inter-facility transfers).

• Air Ambulance.

• Critical Care Transp;it.

3. Inter-fad

In the past, ere hassbeen,spme coestion over whether inter-facility transports pan 64 co w arbd'emergency or non-emergency rariSborts fortkpurpose of establishing an EOA. Based on decisions of state anctlecler4Oprts (A-1 Ambulance v County of Monterey, 0 Fed.RP1*3334515 [1996] and Shaefer's Ambulance v County of San Bernardino '80,-„Cal.Rpt(2d 385 [1998]), if an IFT is rendered by an

mergency anftlance it is an emergency transport. A LEMSA may include „,s in the services restricted to select providers in establishing an EOA, or

it may omit IFTSffrom the EOA designation of services; however, statute and prior court, esisions do not support the establishment of an EOA solely for IFTs.

Under Health and Safety Code section 1797.56, pre-hospital advanced life support staffed by registered nurses must be authorized by the medical director of a local EMS agency.



C. Exclusivity via the "Grandfathering" Process

Under Health and Safety Code, Section 1797.224, an EOA may be established without a competitive process if the local EMS agency's EMS Plan "continues the use of existing providers operating within a local EMS area in the manner and scope in which the services have been provided without tpterruption since January 1, 1981."

1. Manner and Scope Evaluation Criteria — tri ut not limited to the examples below:

a) The following would not constitute a change in the ma and scope:

• Scope of operations has been unc Id since JanuaW1, 1981 (e.g., 9-1-1 only, ALS ernes ulance, etc.).

• If multiple providers serve an area, he economic distribution of calls has not changed since January 1, 1981.

• Number of provide*serviri unchanged since Jan9‘",:4,„:1981. Akexception A lichbe noted a provider Ar9a 8$' if were to RurOassibe,,businaek another provider and reorganize the existing entity

41Z Previders currently operefing in the area have been in continuous

With .tf,Wexception of or boundary changes (e.g., to

minvvii„ s io a ua p 1981. If the service has experienced a

f owners )Aransfer must be a reorganization of the xistihOntity, not merely an assets-only sale.

Npi1,erriiptons in service for any providers serving the area since January 1, -10

accorhOodate construction of a roadway), the geographic area e.cy/Oby the provider, has not changed since January 1, 1981,

tier this comprises the entire area or part of an area.

Note: Upgrades in ambulance services from basic life support (BLS) to advanced life support (ALS) do not affect the eligibility of the area for grandfathering. In addition, a grandfathered provider may subcontract with another provider without jeopardizing its status, as long as the contract terms do not alter the manner and scope of operations.



b) The following would constitute a change in the manner and scope:

• Change in scope of operations since January 1, 1981 (e.g. 9-1-1 only, ALS emergency ambulance, etc.).

• Change in the economic distribution of calls since January 1, 1981 if multiple providers serve an area.

• Change in the number of providers serving an area since January 1981.

• Change in the continuous operations?, in the area since January 1, 19812' a change in ownership.

• Interruption of service sinceA400ary 1, 1981. If, feexample, Provider A served an are from 1981 to 1985, ceased;; operations from 1986-1987, but resumed serviceSjcom 1987-preeent, the manner and scope of services in that a'rea would have been affected.

roViders currently operating assetS-pnly sale constitutes

• Changes to geogre htcprea serviced by the provider since January 1, 1981 (e.g., combiningmultiple areas or splintering existing EOAs into smaller areaS)&

• Ap rove Ja pp I catop,package fromafquall ed, potential provider of service d'the,,area.

o e: Completed provider service applications in an area that is currently exclusive tray--constitute a change in the manner and scope for fUture grandiatnering consideration. However, neither a

er the county may create unreasonable requirements to prevent theilimely review and approval of an otherwise qualified addliCent.

2. Health an pfety Code Section 1797.226

In 1986, Health and Safety Code section 1797.226 became effective. This section refers only to San Bernardino County and creates two provisions: (1) A minor alteration in level of equipment and service does not constitute a change in manner and scope; and (2) A provider that assumes another's service shall qualify as an existing provider if it continued, uninterrupted, the emergency transportation previously supplied by the prior provider. This change in ownership cannot be a simple assets-only transfer.



An example of minor alteration in level of equipment and service would be a change in service from BLS to ALS. An expansion of service from non-transporting to transporting, however, would not qualify as a minor alteration in level of service.

3. Health and Safety Code Section 1797.201

Section 1797.201 allows existing cities and fire districts that provided care (transporting or non-transporting) prior to June #80, to continue services, and can retain administration of ca, long as a LEMSA maintains medical control of care, in accordance with section 1798 et seq. of the code. These entities may exercise this right of administration and enter into a written agreement with at,votmsA for administration of EMS within their jurisdictions. Because section 1797.178 Ofwe code states that advanced life support or limre ,,-:advanced life support Must be an authorized part of the local emergency medibal, services sYS4, these entities should formally coordinate provisiont04hese services with a LEMSA.

The services provided se entities:, Owever, cannot be enhanced; that is, a city or fire district a pot pre** provide transport may not expand its service td#rovi e ort angtetain its rights under this section of tbnocle. (Reference Bernardino v City of San Bemardindr 7<gb4th 90911.0 Rptr.2d444 [1997].)

Sent, can be regilbed, hoWeVer, if the governing body of the city or fire distrai(e.o., city distOtboard), following a public hearing, determinesost that e re JtObessary. The city or fire i continue service-666er this provision if the provider previously

offered L carve and now offers ALS level care, or vice versa, as long as there 60 pen tiqtpansion of service; i.e., from non-transporting first responder"to transporting ambulance.

While Section 1797.201 of the code allows cities and fire districts to continue se es provided prior to June 1, 1980, it does not by itself allow rorkerusroy. txclusivity cannot be granted unless the requirements established/in Section 1797.224 are also met.

4. EMSA Withdrawal of Approval

The EMS Authority may withdraw its prior approval of an EOA previously approved by the "grandfathering" process under the following conditions:

® Significant boundary changes of the area.



Change of manner and scope.

Any information not previously known becomes available.

Once the EMS Authority has withdrawn its approval, the operating area will not receive protection from antitrust actions under Section 1797.6.

D. Exclusivity via the Competitive Process

Establishing an EOA by a competitive process is theimierred method of creating an exclusive operating area. A LEMSA may chpose to conduct the process itself, or it may designate an awarding agetioVi,40 as the relevant county in a multi-county LEMSA, or a fire district alberating'll*,an established area. The awarding agency is responsible4gbanducting thethrecess and managing the contract for the selected Mcifr with a LEMSA'S'AVersight and coordination. For entities that retain administration of care under-ft.0th and Safety Code Section 1797.201, the Citkor,fire department has the right-to administer the competitive process and beInsgM01iance with mandates for a LEMSA regarding medical control, system coordination, and submission of the EMS Transportation Plan an0;keep a LEMSAL4prised of the process.

Section 1797.224 of the Health and Safety Code reOres that the EMS Authority delineate a competitive process'for awarding for,emergency response. The competitive pifid0§-e:49r awarding the?areem(ist at a minimum, address the following:

1. Formal advertising of the oppqrtunity to compete for areas.

2. Development of a-request,Thriproposal which sufficiently states the requirements of the county and requires adequate documentation of

14dersi:EMS capability and fiscal status.

A bidders' conference to provide a forum for answering questions.

Policies for:

d. e. f.

submission of responses; receiving responses;

&Ise evaluation by an impartial evaluation panel; response rejection; award notification; protests and appeals; and contract cancellation



A summary of the necessary steps are outlined below:

• Create an RFP that has been developed in accordance with Section V, "Competitive Process for Creating Exclusive Operating Areas" of this document.

• Submit the draft RFP to the EMS Authority for review (optional). A LEMSA should allow at least 30 days for this review.

• Prior to conducting the RFP, revise the EMS, ransportation Plan to incorporate the EOA into the plan and top4Sbre that the "EMS Systems Standards and Guidelines" raged to the transportation system have been comprehensivelySlOssed in regard to transportation system changes. Tfer teviSibftipshould be submitted to the EMS Authority for reviewl,ndrapprovalitin 60 days of the initial decision to conduct tbeARFP and amend the local EMS Transportation Plan. HoTge\tet if an operating areilwndergoing a repeat competitive proceSta LEMSA need not submit 'e.plan revision within the 60 daY'Veriod andAgY submit noticte' qbf the repeat competitive process wit .?reMS Plan update (see Appendix D forirrel,eyant sectionstrn'the standards and guidelines). In addition, the EMS MS Transportatio' plan is discussed in greater detail under Transportation Plan (seepection III).

• Conduct a fair andqapen co ye;.O?tess with a transparent and equitable ,plicant i r in ''s process must include a

riders conference. competitive process shall be conducted at rast every Myears. Submit a file copy of the final RFP to the MS Authority for its reeajs.

• Include ywith the transport Lion plan revisions a fully completed "Ambulance Zone Summary" form for each operating area and

ovid4Apt the transportation plan and a map of the operating area Appendee t> A).

• Subgt;,te .pibto the EMS Authority for approval.

Submit verification that the county recommends the establishment of thiet;HBOA (e.g., an ordinance or resolution from the County Board

supervisors) in accordance with Health and Safety Code Section )7.85.

If the EMS Authority requests more information or does not approve the transportation plan, a LEMSA will have 30 days to respond. Until the additional information is received and the status of the area clarified, the Authority cannot approve the plan.

If the competitive process is taking place in a non-exclusive zone or a geographic area that has not previously been designated as an ambulance



operating area, as stated in Section IV "Operating Areas," a LEMSA cannot impose a moratorium on the receipt of completed applications to provide service from qualified providers until the contract is in effect for the selected provider.

The EMS Authority may withdraw its prior approval of an EOA via the "competitive" process under the following conditions:

• The contract extends beyond 10 years. Withopl a timely competitive process, the EMS Authority is unable to assniie0at ambulance contract terms do not result in an anticonStitie environment and restrict trade in a given geographic are*tptending a provider contract, obtained through a competitiveProde*beyond 10 years could be construed as allowing for alcfofacto grandfathered" provider.

4 ':4a-44.4

a The awarded provider fails to abii`de by the terms and conditions of the contract.

After the contract has been awarde which are significantly ii

approved RFP.

nanges are made to the ent than those specified in the

• Unfair competitive preots,s prop' rep or selection (i.e. use of biased review panel)

a Seleetion criteria. es descnhed in the competitive process not followed.

etitive Prep.ess not approved by EMSA. • Changes tot

Initial award to a bidder arid- then changed to subsequent awardee after,a,periOdtof operation by the initial bidder.

• Unfair bidding practices by competitors.

Onek,the, EMS Authority has withdrawn its approval, the operating zone will not receive-protectionfrorn antitrust actions under 1797.6.

Review Criteria and Policy for Transportation and Exclusive Operating Area Components of he EMS Plan


V. COMPETITIVE PROCESS FOR CREATING EXCLUSIVE OPERATING AREAS

A. Introduction

If the local EMS agency decides to create EOAs, an RFP shall be developed. An RFP is the awarding agency's requirements, in docurn‘forrn, of specific services to be provided, in addition to other contractySquirements. An awarding agency may be the county or any other cOr Ccauthorized agency.

B. Formal Advertising: Invitations

RFPs should contain the applicable infration enumerated beldkand any other information necessary for proposal eVcalOation. The RFP should alsolntlude the eligibility and evaluation criteria includinglhe, oirif4iYstem to be used in scoring proposals.

RFP information:

1. The serial number of the

2. Name a 5'c:of the

3. Date:A

4. Time nd lace fo rsubmission off responses, including the disposition of late responses potential(reaSbns for rejecting all responses.

lace;;of response opening.

Period` of Which response is to remain in effect.

Guarantee; performance and payment bond requirements.

Bidder's certification that all statements in the response are true. This shall Onstitute aigranty, the falsity of which shall entitle the awarding agency 4utrsue„Atremedy authorized by law, which shall include the right (at

the tartrathe awarding agency), of declaring any contract made as a resultithireof to be void.

9. When needed for the proposal evaluation, pre-award surveys, or inspection, a requirement that bidders state the place(s), including the street address from which the services will be furnished.

10. Description or specification of services to be furnished in sufficient detail to permit open competition. The awarding agency shall obtain and distribute information from current contractors necessary for fair responses by all eligible providers.



11.Time, place and method of service delivery.

12.Citation of, and required bidder conformance to, all applicable provisions of law and regulations.

13. Requirement for each bidder to submit a detailed budget and budget narrative wherein line items are identified as yearly or contract period costs.

C. Bidders' Conference

The awarding agency should conduct a bidders' conference at a pre-designated time during the early stage of the process. The OW ante time of the conference should be stated in the RFP, or arrangements should be made for contacting RFP recipients. A

The purpose of the bidders' conference is to provide a forum for answering bidder's questions. The conference sheibldbe theonly time that general questions are answered regarding the RFP4Thip',will ensure that all prospective bidders receive the same information. Questions and answers should be put in writing, but need not be su6Mitteq!prior to the conference. If a written response to a question is provided then all prde Olive biddere3Must receive a copy of the question and the answer.

D. Proposal Contents

1. The RFP,,enould require bidders 0,eubmit a statement of experience which shall include; but not litre to fr following information:

Business name and legal blisiness status (i.e., partnership, corporation, etc.) of the prospective contractor.

b. Numbefcof yeatelbe prospective contractor has been in business under thefpresent business name, as well as related prior business names.

NIumberof, 'years of experience the prospective contractor has had in royidinsithe required services.

Contracts completed during last five (5) years showing year, type of services, dollar amount of services provided, location, and contracting agency.

e. Details of any failures or refusals to complete a contract.

f. Whether the bidder holds a controlling interest in any other organization, or is owned or controlled by any other organization.

g. Financial interests in any other related business.

d.



h. Names of persons with whom the prospective contractor has been associated in business as partners or business associates in the last five (5) years.

i. Explanation of any litigation involving the prospective contractor or any principal officers thereof, in connection with any contract for similar services.

j. Explanation of experience in the service to bet provided or similar experience of principal individuals of the prospective contractor's present organization.

k. List of major equipment to be used for thei] eict provision of services.

I. The awarding agency should request „, ncial:normation which will disclose the true cost of the proposed Speration*the intended source of all funding related to the;frovision of se-Wipes as specified in the RFP. This may include current financial statemerW„ketters of credit, and guarantor letters from related entities, as welits other materials required by the awarding agency

m. A list of commitments, and potential commitments which may impact assets, lines of credltrguarantor letters, or otherwise affect the bidder's ability to perform ract.

AM, n. Business or professional lice e or certificates required by the nature

,, ta, i'of the contract work tO:flip performed held by the bidder.

o. An agreement to provide:, warding agency with any other infolMIion thel'%unty deteViiines is necessary for an accurate

antlita,a*“( g agency to audit the prospective

determination otthe prosp'e'ctive contractor's qualifications to perform servcces. ei. ,, , ,-

„

tractbrieffinancial and ether records.

othr in

he proposal process should require that:

s should be submitted so as to be received in the office designated in the RFP document not later than the exact time set for subrhission of responses.

b. Proposals, with required attachments, should be submitted in the format specified by the awarding agency, and signed. The format should provide for the desired sequence of the proposal's content and a model budget.

c. Proposals should be filled out, executed, and submitted in accordance with the instructions which are contained in the RFP. If the proposal is



not submitted in the format specified, it may be considered only if the bidder meets and accepts all the terms and conditions of the RFP.

2. Any proposal received at the office designated in the RFP after the exact time specified for receipt should not be considered unless it is received before award is made and either:

a. The awarding agency has set forth an option, to be contained in the RFP document, for acceptance of proposals by, or certified mail, sent prior to the date specified for the receipt of proposals.

b. It is determined that the late receipt was due,,aolely to mishandling by the awarding agency after receipt at the agency.

3. Acceptable evidence to establish whetter proposal is ate or meets some of the exceptions listed above may

a. The date of mailing of a propO01, proposakmodification,'or yithdrawal sent either by registered or certified moils the U.S. Postal Service postmark on the wrapper or on the receipt from the U.S. Postal Service. If neither pdstmark shows a legible date, the proposal, modification, or withdrawal should be deemed to have been mailed late.

b. The time of receipt at the, away in aocy is the time-date stamp of such a,.64iesds) the proposal*rapper Ofither evidence of receipt.

4. Any modification or withdrawal 0e proposal should be subject to the same conditions cited obeys'.

'::

A proposal ma also be withdrawn„.16 person by a bidder or an authorized epresentatiVacprevided his/her identity is made known and he/she signs a

receiptfOr the Proposal, but only if the withdrawal is made prior to the exact time set fo*Openinglofproposals.

F. Receipt and Evaluation of Proposals

1. UporiTepat ; ,each proposal should be noted with a separately identifiable propoeelf4rhber, the date and time of receipt.

2. All proposals received prior to the time set for opening should be kept unopened and secured in a locked receptacle.

3. An agency official should decide when the time set for submission has arrived and should declare that to those present. All proposals received prior to the time set for opening should be publicly opened, recorded, and read aloud to the persons present:

a. RFP number.



b. Submission date. c. General description of service being procured. d. Names of bidders. e. Amounts proposed. f. Any other information the awarding agency determines is necessary.

4. If the number of proposals received is less than anticipated, the awarding agency should examine the reasons for the small number of proposals received. The purpose of this examination is to ascertain whether the small number of responses is attributable to an absence, any of the prerequisites of formal advertising.

5. Should administrative difficulties be encountered after proposal opening which may delay contract award beyorAlhe'state deadline for contract award, the bidders should be notifiesilfore that date and acceptance period extended in order to avoid t teed for re-advertisant.

6. Review of proposals by an impartlaltayaluatiSam.

G. Rejection of Proposals

1. Any proposal which fails to conform essential requirements of the RFP documents, such as speificatjo he delivery schedule, should be , rejected ae,tniiharesponsive. Proposals suhthitted which do not meet the require50‘regardIng resporMipility should also be rejected. When rejecting a proposaldtihe awardinggency should notify each unsuccessful bidder'that„ the proposal as beediajected.

osal should not be rejects 'when it contains a minor irregularity or en defect onVpriation is immaterial or inconsequential. A minor

irregularity, means or variation which is merely a matter of form and not of subelaSe, stieN;ap:

Failure ot:the bidder to return the required number of copies of signed proposa

Clerical errors.

3. immaterialor inconsequential means that the defect or variation is insignificant as to price, quantity, quality, or delivery when contrasted with the total costs or scope of the services being procured.

4. The awarding agency may give the bidder an opportunity to cure any deficiency resulting from a minor informality or irregularity in a proposal or waive such deficiency, whichever is to the advantage of the awarding agency.



H. Contract Periods

1. The complete process (Requests for Proposals) must be repeated at periodic intervals. The period between RFP requests should be established by local EMS agency policy based upon population, initial investment in provision of service and other relevant factors but not greater than ten years.

2. Contracts should be reviewed annually, at which e they may be renegotiated if this option is included in the contract.ik contract may be renewed for a certain period, not to exceedflen totally ars, without a repeat competitive process if this is stated in the OP. ,

n eegotiated with the contractor beSed on th fo .-. 3. The rate of reimbursement for adfiltihe1 terms under the contract should be wing:

a. Actual expenditures by the c°::::::_i.!documented during the first

c. Other reasonable costs or increases in costIbver which the contractor

b. Changes in state program requirements.

contract term and approved by the*Varding agency.

,,,, . has no ccntrol. ,

4. In negotiating costs,jhe awarding agency should assure that these costs accurately reflect current contract performance and are not inflated to recover costs which ma have been, understated by the contractor during the original RFP ,„

e awarding agency should assure, by audit if necessary, that all cost increases, are reasonable and necessary to the continuation of the contract.

I. Pretests

The awarding Nertcy should consider any protest or objection regarding the award of a-cpntrpct, whether submitted before or after the award, provided it is filed within the:time period established in the RFP. Written confirmation of all protests shall be requested from the protesting parties. The protesting party should be notified in writing of the awarding agency's decision on the protest. The notification should explain the basis for the decision. The decision of the awarding agency regarding the protest may be appealed to a higher authority.



J. Canceling the Procurement Process after Opening

1. The procurement process may be canceled after opening, but prior to award, when the contracting officer determines in writing that rejection of all proposals is in the best interest of the agency for reasons such as those listed below:

a. Inadequate, ambiguous, or otherwise deffq tspecifications were cited in the RFP.

b. The services are no longer required.,

c. All otherwise acceptable proposals proposaals received exceed sdgeted funds.

d. The proposals were not independently arrived at in opeSsompetition, were collusive, or were submitted in bad faith.

nimum requirements of the e. No proposal is received which RFP.

f. The awarding agency determines after, alysis of the proposals that its needs can be satisfied ethod offier than called for in the proposal's requiremektS,

2. All bidder&Sbou e.notified* ing of th'eifiecific reasons when proposalsc are rejected:,



APPENDICES (Appendix A — D)



Appendix A

EMS Plan Update Ambulance Zone Summary Form (revised May 2007

Date:

Local EMS Agency or County Name:

Area Description (e.g. Zone 1, Zone A): Title (e.g. Northwest County): Geographic Description (a c )

Total Service Area Size: ..qe, Population: NS

Current Provide s))`0 e (include legal, fictitious, ancldba): 4.55. ,,,yf;, c5. r --c,4? (,situ-'5, v -.4

v.❑ Non Exclusive x0 OSII ,i L.:" 7Type ofexplusivity: Check499;box

, ,,, 3,-„„ LI Emergency ,:At.,,,i,

El 4 v#nced Life Support (ALS)

0 yruited Advance Life Support (LALS) --

t--

Le7skeligf Exclusivity: Chal'ime box

0 *emergency Ground Ambulatice (This

,1 A 1\ includes,iptet-

ly

7 digit

acility transfers) nsi

numbers)

55...

II Emergency Ground Ambulance (9-1-1 o '>x<5,t---*

❑ Etribirgbbcy Ground Ambulance (9-1-1 and

,;..,,,-0 Air Arnimlbrice



Method to Achieve Exclusivity, if applicable (HS 1797.224):

If requesting exclusivity via grandfathering or competitive process, attach documentation of the board action.*

Grandfathered (If requesting to grandfather current providers, please complete the Grandfathering Checklist and attach.*)

❑ Competitive Process: List contract dates. (Submit a copy of the request for proposal and provider contract.*)

*If this information has been previously submitted and the EMS Uthority has approved the plan, it is not necessary to re-submit. Has there been any change in manner and scope since thpjlitt apprOved EMS plan update (e.g., boundary changes, ownership changes)? et OW



Appendix B — Grandfathering Checklist (new May 2007)

In accordance with Health and Safety Code section 1797.224, a local EMS agency may consider grandfathering providers when establishing exclusive operating areas. Please complete the following documentation in support of a request to grandfather providers. Any missing or incomplete submissions may affect the EMS Authority determination regarding the eligibility for grandfathering.

1. Operating Area Name arjd Deseriptio, adjacent zone ., i

V) .'

(attach map including

2. HaOccera etitive process ever been bw

f) s, list the prpv r `start a e

conducted, thi area? III Yes

and eV of agremoment:

3. Type of ServiceEmergeridy ALS • BLS

4. , Organization Name (inclu elegal fictitious, and dba):

5. Address (headquarters a ke '010116.11): -,,

a-T.7J 6. Type of Organization-(e.g , corporation,

joint powers authority). partnership, public agep4,1

..m::-. 7. Month/Year Service Began:

51 8. List any Breaks in Seryic0iPfrludelerigith how zone(s) were serviced during

_ ___,

of each break, reasomil d thetreak):

. t k

Any changes in population in the i01/01/81? (Include supporting demographic

described zone/service areflince data): El Yes" No

W.' Any changes in zone boundaries/service

population

maps illustrating

ata ffor

by call volume

area since 01/01/8TR If so,

affected:

gun a ,changes:

a(e) and list data source:

please: (3) Describe and include

kA,a '(2) Al h kclearly labeled

iii ,-. ,,, t,,,J,'

(3) Include call fl ute

(4) List any providers affected volume data and projected

ed

the change. Include prior call following change.



11. Any changes in ownership? For each change since 01/01/81, please: (1) List changes in names:

(2) List dates of ownership changes [include a copy of contract and/or sale/transfer agreement(s)]:

(3) Answer the followingalel ions. (a) DisposItiontef aseTttailikTere)alli alisitOr gerred to new

.4 owner(shYes.. ri No (Please explain)

ofer of employees: Were ell \employees hirkeLb rt. owner(s)? No ease, a i=plain)

(c) Disposition of accounts payable and eceivable: Were accounts payablearid receivable transferred? E Yes No: Please explain.

'Since 01/01/81, have any other proyidrs served all or part of this 'zone? If so, please ansWerthel,wing-iiiiestions:

(a) Are the providers currentli)n operatibp? Please list all '- 2̀.providers, their ley& of se vice (emergency, ALS, BLS) and Lk' explain if they will Jae grautlfathere'd •

rf

(b) If the provider(s) no longer-serves the area, please list level of service, dates of service, and reason for termination of,, service.

ES



Appendix C - Applicable Health and Safety Code Sections

1797.6. (a) It is the policy of the State of California to ensure the provision of effective and efficient emergency medical care. The Legislature finds and declares that achieving this policy has been hindered by the confusion and concern in the 58 counties resulting from the United States Supreme Court's holding in Community Communications Company, Inc. v. City of Boulder, Colorado, 455 U.S. 40, 70 L. Ed.2d810, 102 S. Ct. 835, regarding local governmental liability under federal antitrust laws.

(b) It is the intent of the Legislature in enacting this section,and,tections 1797.85 and 1797.224 to prescribe and exercise the degree of stat •pction and supervision over emergency medical services as will provide for stateac immunity under federal antitrust laws for activities undertaken by local governritelital entt s in carrying out their prescribed functions under this division.

emergency medical services plan for which go EMS agency, upon thecq't,„,recommendation of a county, restricts operat on 4 onpligt'inore emergency ambulance services or providers of limited advanced life suPl5,P!,{a:Ivanced life support.

medical services and trauma care syStams

1797.85. "Exclusive operating area" means: EMSL are ub-areedbfined by the

1797.105. (a) The authority shall reCtSijilans,for the implementation of emergency • .y- ,, ,.,

,,:7•••,:-,77;:ti

ELVIS a aes.

r,

(b) After the applicable guidelines or Static w ablished by the authority, a ,

'.):k ,;„ , local EMS agency may implement a locattp evelopethpursuant to Section 1797.250, 1797.254, 1797.2579,72071797.25049nless i•••authority determines that the plan does not effectively meet ttipiihipeds of the persons seated and is not consistent with coordinating activities in the geographical area served, or that the plan is not concordant and consistent with applicable pi me regulations, or both the guidelines and regulations, establishe 'by the authority

t7L5-1-”,(c) Alkai EMS agency ma peal a determination of the authority pursuant to

4 S,101 subdoittpn (b) to the commission

1„,:fg,, ;,__ (d) In 'MVP:appeal pursuant lo subdivision (c), the commission may sustain the • ,,,,,, ,,.. - determinatighicpf the authority or overrule and permit local implementation of a plan, and the decisiontfEttie commission is final.

1797.200. Each diSCZaci develop an emergency medical services program. Each ttive

county developing such a program shall designate a local EMS agency which shall be the county health department, an agency established and operated by the county, an entity with which the county contracts for the purposes of local emergency medical services administration, or a joint powers agency created for the administration of emergency medical services by agreement between counties or cities and counties pursuant to the provisions of Chapter 5 (commencing with Section 6500) of Division 7 of Title 1 of the Government Code.



1797.201. Upon the request of a city or fire district that contracted for or provided, as of June 1, 1980, pre-hospital emergency medical services, a county shall enter into a written agreement with the city or fire district regarding the provision of pre-hospital emergency medical services for that city or fire district. Until such time that an agreement is reached, pre-hospital emergency medical services shall be continued at not less than the existing level, and the administration of pre-hospital EMS by cities and fire districts presently providing such services shall be retained ?y, those cities and fire districts, except the level of pre-hospital EMS may be reduced re the city council, or the governing body of a fire district, pursuant to a public hewing, determines that the reduction is necessary.

Notwithstanding any provision of this section the proyisions of Chapter 5 (commencing with Section 1798) shall apply.

1797.204. The local EMS agency shall plan, iMPlement, and evaluate an aipergency medical services system, in accordance with ̀ theyprovisioriS,of this part, consisting of an organized pattern of readiness and response services baservices4based on public and private agreements and operational procedures.

1797.206. The local EMS agency shall e responsible forrimplementation of advanced life support systems and limited advanced life-support systems, and for the monitoring of training programs.

1797.220. The local EMS agency, using stat minimum standards, shall establish policies and procedures approved. by the medical director of the local EMS agency to assure medical control of the EMS eystem tile,„‘policies and procedures approved by the medical director May2.redtire'basicilketgdert emergency medical transportation services to meet any mediae] control requirements including dispatch, patient destination policiee, patient care guidelines, and quality assurance requirements.

1797 224. A local EMS -o6ency'rn4ycreate one or more exclusive operating areas in the development of a local plan, if a competitive process is utilized to select the provider or

', providers df-the services pursuant to the plan. No competitive process is required if the local EMS agency devetoOe or implements a local plan that continues the use ofexisting providers operating within a local EMS area in the manner and scope in which the services have Peetillifovided without interruption since January 1, 1981. A local EMS agency which elects to create one or more exclusive operating areas in the development of a local plan shall develop and submit for approval to the authority, as part of the local EMS plan, its competitive process for selecting providers and determining the scope of their operations. This plan shall include provisions for a competitive process held at periodic intervals. Nothing in this section supersedes Section 1797.201.



1797.226. Without altering or otherwise affecting the meaning of any portion of this division as to any other county, as to San Bernardino County only, it shall be competent for any local EMS agency which establishes exclusive operating areas pursuant to Section 1797.224 to determine the following:

(a) That a minor alteration in the level of life support personnel or equipment, which does not significantly reduce the level of care available, shall not constitute a change in the manner and scope of providing service. '

(b) That a successor to a previously existing emergency selges provider shall qualify as an existing provider if the successor has continued uniarfupted the emergency transportation previously supplied by the prior provide

1797.254. Local EMS agencies shall annually supraplan for the EMS area to the authority, according to Systems, Stanttayds, and

an emergency medical services

Guidelines established by the authority. rt



Appendix D: Relevant Sections of the EMS System Standards and Guidelines (EMSA•#101, June 1993)

• Planning Activities — Section 1.09

• Enhanced Level: Exclusive Operating Areas - Section 1.28

• Response/Transportation - Sections 4.01, 4.02, 4.04 4.06, 4.13

• Enhanced Level: Ambulance Regulation — Section:

• Enhanced Level: Exclusive Operating Permits, Section 4. 4.22

• Enhanced Level: Exclusive Operating 4*Nts/Ambulance RegulatiO — Section 8.19



EXHIBIT C

STATE OF CALIFORNIA— HEALTH AND HUMAN SERVICES AGENCY ARNOLD SCHWARZENEGGER, Governor

EMERGENCY MEDICAL SERVICES AUTHORITY 1930 9th STREET CACRAMENTO, CA 95811-7043

;6) 322.4336 FAX (916) 324-2875

June 20, 2009

Virginia Hastings, Executive Director ICEMA 515 N. Arrowhead San Bernardino, CA 92415-0080

Dear Ms. Hastings:

We have completed our review of 10EMA's 2007 Emergency Medical Services Plan Update, and have found it to be in compliance with the EMS System Standards and Guidelines and the EMS System Planning Guidelines, with the exception of ICEMA's Transportation plan. Following are comments on the EMS plan update:

Standard 1.27 & 5.10 Pediatric Emergency Medical and Critical Care System -In your 1999 EMS Plan your objective was to develop a comprehensive emergency medical and critical care system plan for children. While this is an enhanced level standard, I recommend you review the "Development and Implementation of EMSC, a Step by Step Approach", found on our web site at htto://vvww.emsa.ca.qov/systems/files/EMS-C.pdf.This document provides information to Local EMS Agencies interested in developing an EMS for Children program.

Transportation Plan

The transportation portion of ICEMA's EMS Plan has not been approved. The issues with ambulance zones in San Bernardino County are specified below as stated in our letter to you dated April 21, 2008:

Areas 1 and 2 — Section 1797.224 states an existing provider can continue to operate within the same manner and scope in which the services have been provided without interruption since January 1, 1981. Due to the fact that two providers were operating in the area prior to 1982, when Schaefer Ambulance Service ceased operations for a six month period in 1982, the manner and scope of operations changed within Areas 1 and 2, Based upon this AMR does not qualify for non-competitive exclusivity under §1797.224.

Areas 12 and 25 — The Authority does agree that based on their 1797.201 responsibilities, Lucerne Valley Fire can continue to provide the same emergency services as it has done since June 1, 1980. Zones 12 and 25 no longer qualify for exclusivity due to the annexing of the Lucerne Valley Fire jurisdiction into these zones. The annexation has changed the manner and scope of the zone due to the significant boundary change, including noncontiguous areas. Therefore, Zones 12 and 25 as described in ICEMA's ambulance

Virginia Hastings June 20, 2009 Page 2

zone summary form will not be recognized as exclusive by the EMS Authority. §1797.224 of the Health and Safety Code will not be applicable.

Area 19 - The information provided indicates exclusivity based on the Running Spring Fire Department or "predecessors" have been delivering uninterrupted services to this area prior to 01/01/81. The usage of the word "predecessors" has led the Authority to believe that the Running Spring Fire Department may not have been providing service in Area 19 since 01/01/81. Please verify if the Running Springs Fire Department, has in fact, been the only entity providing uninterrupted emergency services in the same scope and manner since 01/01/81.

Area 20 - The ambulance summary form submitted by ICEMA states the provider for Area 20 was selected through the RFP process in 1985. As previously stated under §1797.224; a competitive process is to be held at periodic intervals, no greater than 10 years. Without a timely competitive process, the EMS Authority is unable to assure that ambulance contract terms do not result in an anticompetitive environment and restrict trade in a given geographic area. Extending a provider contract, obtained through a competitive process, beyond 10 years could be construed as allowing for a "defacto non-competitive exclusive" provider. For Area 20 to remain as an exclusive area, a new competitive process must be initiated.

For these ambulance zones to remain exclusive and maintain protection under state action immunity, a competitive process would be required. Please contact Tom McGinnis (916) 322-4336, extension 412, if you have any questions on the transportation plan review.

Your annual update will be due on June 20, 2010. If you have any questions regarding the plan review, please call Sandy Salaber at (916) 322-4336, extension 423.

Sincerely,

'7 R. Steven Tharratt, MD, MPVM Director

EXHIBIT D

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY

EMERGENCY MEDICAL SERVICES AUTHORITY 10901 GOLD CENTER DRIVE, SUITE 400 RANCHO CORDOVA, CA 95670

EDMUND G. BROWN JR. , Governor

) (916) 322-4336 FAX (916) 324-2875

)

j

July 19, 2012

Denice Wicker-Stiles Acting Director Inland County 515 N. Arrowhead San Bernardino, CA 92415-0060

Dear Ms. Wicker-Stiles

We have completed our review of Inland County's 2010 Emergency Medical Services Plan Update, and have found it to be in compliance with the EMS System Standards and Guidelines and the EMS System Planning Guidelines. Following are comments on the EMS plan update:

Standard 1.27 & 5.10 - Pediatric Emergency Medical and Critical Care System -In Inland County's 2009 EMS plan update you stated that you were implementing an EMSC program. In your next EMS plan update please explain how the pediatric emergency medical and critical care system was implemented for Inland Counties.

Transportation Plan:

lnyo County

OAs 1. 4. and 5: A RFP process was initiated in January 2006, and the contract was awarded in November 2006. Pursuant to Section 1797.224, if a LEMSA elects to create an exclusive operating area it shall submit for approval to the Authority its competitive process for selecting providers and determining the scope of their operations. The Authority has yet to receive the RFP for these zones. Please submit copies of the RFPs and the fully executed agreement for each zone by August 19, 2012.

OAs 2 and 3: The AZS forms state each zone is exclusive without a competitive process with a level of exclusivity to include BLS inter-facility transfers (1FT) . Please provide documentation, by August 19, 2012, which supports that Big Pine RescueOA 2 and Independence Volunteer Fire Department - OA 3 have been the only providers offering BLS 1FT since January 1, 1981. Until receipt of the requested documentation the Authority will not recognize ALS 1FT as an exclusive level of exclusivity.

Denice Wicker-Stiles July 19, 2012 Page 2

Mono County

OA 1 and 2: The AZS forms state each zone is exclusive without a competitive process with a level of exclusivity to include ALS inter-facility transfers (1FT). Please provide documentation, by August 19, 2012, which supports that Mono County Paramedic Program has been the only provider offering ALS 1FT in these zones since January 1, 1981. Until receipt of the requested documentation, the Authority will not recognize ALS 1FT as a level of exclusivity.

San Bernardino

OA 5: The AZS forms state this zone is exclusive without a competitive process with a level of exclusivity to include all inter-facility transfers (1FT). Please provide documentation, by August 19, 2012, which supports that AMR has been the only provider offering all 1FT since January 1, 1981. Until receipt of the requested documentation, the Authority will not recognize 1FT as a level of exclusivity.

OA 12 and 25: The AZS forms state each zone as being exclusive without a competitive process. Due to the division of OA 12 into two (2) separate zones, listed as OA 2 and OA 25, disqualifies both zones as being exclusive without a competitive process. The annexation of the Lucerne Valley Fire jurisdiction into these zones changed the manner and scope of the zone due to the significant boundary change, including noncontiguous areas. Prior to the annexation by the County Fire, OA 12 was exclusive without a competitive process with AMR and Lucerne Valley Fire (San Bernardino County Fire) being the providers. Based on our review of the information available, ICEMA has two options available:

Option 1 : Have OA 12 as one exclusive operating area encompassing the two providers operating in the zone. This option is based on our prior approval of your 2002 EMS Plan with OA 12 as a single zone with two (2) providers. A new AZS form will be required showing this zone as being exclusive without a competitive process.

Option 2: Have OA 12 and OA 25 as two (2) separate zones operating non-exclusively. A new AZS form will be required for each OA showing the zones as being non-exclusive.

Please submit new AZS forms, based upon the determination of option 1 or option 2 by ICEMA by August 19, 2012. Until receipt of the new AZS forms, the Authority will recognize OA 12 and OA 25 as being non-exclusive.

Denice Wicker-Stiles

Denice Wicker-Stiles July 19, 2012 Page 3

OA 20: A RFP process was conducted in 1985. Section 1797.224 states that the competitive process is to be held at periodic intervals. With more than 25 years passing since the last competitive process, the periodic interval requirement has not been met and the Authority will recognize this zone as being non-exclusive. For this zone to be exclusive, a new competitive process will need to be initiated. Please submit, by August 19, 2012, a revised AZS form showing this zone as being non-exclusive.

Based on the documentation you provided please see the attachment on the EMS Authority's determination of the exclusivity of Inland County's ambulance zones.

Your annual update will be due on July 19, 2013. Please submit Inland County EMS Agency's 2012 Trauma System Status Report, as a separate document, with your EMS Plan Update. If you have any questions regarding the plan review, please call Sandy Salaber at (916) 431-3688.

Sincerely,

I Howard Backer, MD, MPH, FACEP Director

Attachment

EXHIBIT E

~ ~ ~

~'~~~ ~ ~ ~

~W rty

~an 6c~rn ~d no Ca ny

Prepared for:State EMS Authority

By:Tom Lynch, EMS AdministratorInland Counties Emergency Medical AgencyApril 15, 2015 (Revised)

EMS PLANAMBULANCE OPERATING AREA SUMMARY FORM

In order to evaluate the nature of each area or sub area, the following information should be compiledfor each operating area individually. Please include a separate form for each exclusive and/ornonexclusive ambulance operating area.

Local EMS Agency or County Name: Inland Counties Emergency Medical AgencySan Bernardino Count

Area or sub area Name or Title: Exclusive Operating Area #12: Subarea A and Subarea BAdelanto, Victorville, Apple Valley, Lucerne Valley and surrounding unincorporated areas

Name of Current Provider(s):Include company names) and length of operation (uninterrupted) in specified area or sub area.

Multiple providers

American Medical Response (AMR)

San Bernardino County Fire Department

Area or sub area (Zone) Geographic Description:(12a) This area comprised of Victorville, Adelanto, Apple Valley and surrounding unincorporatedareas, unincorporated area east of 12b services provided by the EOA provider AMR.

(12b) This area comprised of Lucerne Valley and surrounding unincorporated area.

Statement of Exclusivity, Exclusive or non-Exclusive (HS 1797.6):Include intent of local EMS agency and Board action.

Exclusive -Meets grandfathering requirement of 1797.224 and 1797.226.

Non-exclusive

Type of Exclusivity, Emergency Ambulance, ALS, or LALS (HS 1797.85):Include type of exclusivity (Emergency Ambulance, ALS, LALS, or combination) and operational definition of exclusivity(i.e., 911 calls only, all emergencies, all calls requiring emergency ambulance service, etc.).

(12a) Emergency ambulance; 9-1-1 emergency response, ALS; IFT, SCT(12b) Emergency ambulance; 9-1-1 emergency response, ALS

Method to achieve Exclusivity, if applicable (HS 1797.224):If grand fathered, pertinent facts concerning changes in scope and manner of service. Description of current providerincluding brief statement of uninterrupted service with no changes to scope and manner of service to zone. Includechronology of all services entering or leaving zone, name or ownership changes, service level changes, zone areamodifications, or other changes to arrangements for service.

This provider or its predecessor has delivered uninterrupted service with no changes to scope andmanner of service to the operating area since prior to January 1, 1981.

EMSA's opinion letter regarding 1797.224 and/or 1797.226 status.

If comgetitivety determined, method of competition, infervals, and selection process. Aftach copy/draft of lastcompetifive process used to se/ecf provider or providers.

EMS PLANAMBULANCE OPERATING AREA SUMMARY FORM

In order to evaluate the nature of each area or sub area, the following information should be compiled

for each operating area individually. Please include a separate form for each exclusive and/ornonexclusive ambulance operating area.

Local EMS Agency or County Name: Inland Counties Emergency Medical Agency -San Bernardino Count

Area or sub area Name or Title: Operating Area #25

Name of Current Provider{s):Include company names) and length of operation (uninterrupted) in specified area or sub area.

Liberty Ambulance Service has provided 9-1-1 calls only - AL.S (mutual aid) in the area pursuant

to the EMS Transportation Plan adopted June 18, 1985.

Area or sub area (Zone) Geographic Description:

This area is comprised of Highway 395 from the Kern County line to north of Hwy 58.

Statement of Exclusivity, Exclusive or non-Exclusive (HS 1797.6):Include intent of local EMS agency and Board action.

Exclusive -Meets grandfathering requirement of 1797.224 and 1797.226.

~X Non-exclusive

Type of Exclusivity, Emergency Ambulance, ALS, or LALS (HS 1797.85):Include type of exclusivity (Emergency Ambulance, ALS, LALS, or combination) and operational definition of exclusivity

(i.e., 911 calls only, all emergencies, all calls requiring emergency ambulance service, etc.).

Method to achieve Exclusivity, if applicable (HS 1797.224):If grandfathered, pertinent facts concerning changes in scope and manner of service. Description of current provider

including brief statement of uninterrupted service with no changes to scope and manner of service to zone. Includechronology of all services entering or leaving zone, name or ownership changes, service level changes, zone area

modifications, or other changes to arrangements for service.

RFP process conducted in January 2007. No responses received and area remains non-

exclusive.

if comnetitively determined, method of competition, intervals, and se%ction process. Attach copy/draft of last

com efitive rocess used to select provider or roviders.

STATE OF CALIFORNIA —HEALTH AND HUMAN SERVICES AGENCY EDMUND G. BROWN JR., Governor

EMERGENCY MEDICAL SERVICES AUTHORITY1Q901 GOLD CENTER DR., SUITE 400RANCHO CORDOVA, CA 95670

(916) 322-4336 FAX (916) 322-1441

May 12, 2017

Mr. Tom Lynch, EMS AdministratorInland Counties EMS Agency1425 South "D" StreetSan Bernardino, CA 92415

Dear Mr. Lynch:

This letter is in response to Inland Counties EMS Agency's 2013 EMS Plan Updatesubmission to the EMS Authority on April 15, 2015.

I. Introduction and Summary:

The EMS Authority has concluded its review of Inland Counties EMS Agency's 2013EMS Plan Update and is approving the plan as submitted.

11. History and Background:

Inland Counties EMS Agency received its last full plan appravai for its 1999 plansubmission, and its last annual plan update for its 2010 plan submission.

Historically, we have received EMS Plan submissions from Inland Counties EMSAgency for the following years:

• 1999 2009• 20Q6 2010• 2007

Health and Safety Code (HSC) § 1797.254 states:

"Local EMS agencies shall annually (emphasis added) submit anemergency medics! services plan for the EMS area to the authority,according to EMS Systems, Standards, and Guidelines established by theauthority"

The EMS Authority is responsible for the review of EMS Plans and for making adetermination on the approval or disapproval of the plan., based on compliance with

Mr. Tom Lynch, EMS AdministratorMay 12, 2017Page 2 of 3

statute and the standards and guidelines established by the EMS Authority consistentwith HSC § 1797.105(b).

Ilt. Analysis of EMS System Components:

Following are comments related to Inland Counties EMS Agency's 2013 EMS PlanUpdate. Areas that indicate the plan submitted is concordant and consistent withapplicable guidelines or regulations, HSC ~ 1.797.254, and the EMS systemcomponents identified in HSC § 1797.103, are indicated below:

NotApproved Approved

A. ~x ❑ System Organization and Management

B. O ❑ Staffing/Traininq

C. Ll ❑ Communications

D. D D Response/Transportation

7. Ambulance Zones

• Based on the documentation provided by Inland CountiesEMS Agency, please find enclosed the EMS Authority'sdetermination of the exclusivity of Inland Counties EMSAgency's ambulance zones.

E. D ❑ Facilities/Critical Care

F. D ❑ Data Collection/System Evaluation

G. ~ D Public Information and Education

H. D O Disaster Medical Response

IV. Conclusion:

Based on the information identified, Inland Counties EMS Agency's 2013 EMS PlanUpdate is approved.

Mr. Tom Lynch, EMS AdministratorMay 12, 2017Page 3 of 3

Pursuant to HSC § 1797.105(b):

"After the applicable guidelines or regulations are established by theAuthority, a local EMS agency may implement a local plan...unless theAuthority determines that the plan does not effectively meet the needs ofthe persons served and is not consistent with the coordinating activities inthe geographical area served, or that fhe plan is not concordant andconsistent with applicable guidelines or regulations, ar bofh the guidelinesand regulations established by the Authority."

V. Next Steps:

Inland Counties EMS Agency's 2017 EMS Plan Update will be due on or beforeMay 31, 2018. If you have any questions regarding the plan review, please contactMs. Lisa Galindo, EMS Plans Coordinator, at (916) 431-3688.

Sincerely,

Howard Backer, MD, MPH, FACEPDirector

Enclosure

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EXHIBIT F

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY EDMUND G. BROWN JR., Governor

EMERGENCY MEDICAL SERVICES AUTHORITY 10901 GOLD CENTER DR., SUITE 400

RANCHO CORDOVA, CA 95670

(916) 322-4336 FAX (916) 322-1441

December 13, 2017

Pat Frost, EMS Director Contra Costa County EMS Agency 1340 Arnold Drive, Suite 126 Martinez, CA 94553

Dear Ms. Frost:

RECEIVED DEC 18 2011

CONTRA COSTA EMERGENCY MEDICAL SERVICES

This letter is in response to your correspondence dated, November 16, 2017, requesting the Emergency Medical Services (EMS) Authority to approve an extension of exclusivity for Contra Costa EMS — Emergency Response Area (ERA) IV Request for Proposal (RFP) process. Per an EMS Authority letter, dated September 9, 2016, ERA IV will expire on October 21, 2018. The EMS Authority has reviewed your RFP for and we are denying your request for an extension of the exclusive operating area of ERA IV.

The last EMS Plan Update, that the Authority approved, was on September 2, 2016, with ERA IV being exclusive through a competitive process. Historically, the San Ramon Valley Fire Protection District has been well served through the use of a competitive process unambiguously providing service to the ERA IV exclusive operating area. Based upon our preliminary review of the Zone, we took the following factors into consideration of your request:

• There have been multiple agreements between Contra Costa County and the district that describe the system integration and participation of the San Ramon Valley Fire Protection District.

• Once an agreement between a city or fire district for integration into a local EMS system is completed, Health and Safety Code section 1797.201 is no longer applicable.

• The application of HS 1797.224 is the only recognized method to achieve exclusivity as part of an EMS plan. HS 1797.201 does not confer exclusivity.

• San Ramon Valley Fire Protection District may have provided BLS ambulance service in 1980, but we see no evidence that the district provided ALS services based upon the documentation in the agreements.

• Additional ambulance transport entities served the area, including ALS response and transport from John Muir Memorial Hospital, Dublin/San Ramon Services

P. Frost December 13, 2017 Page 2

District, and perhaps additional providers. This arrangement would disqualify the district from exclusivity without a competitive process.

• The merger of the Tassajara Fire Protection District in 1991 and a portion of the Dougherty Regional Fire Authority in 1997 (the portion that did not go to Alameda County), and the ambulance providers to those historical zones would need analysis to determine if there were continuous operations or other additional operators served the area. However, additional analysis may not be necessary as the transport provisions from John Muir and Dublin/San Ramon serve to show that multiple providers were in the zone.

• The realignment of the emergency response areas in Contra Costa County and from ten (10) to five (5) in 1984 may further complicate the assessment that the geography and call distribution of the zones has remained the same.

• The presence or absence of a competitor, in previous bids, is not a factor in determining whether to continue or discontinue a competitive process.

If the competitive process is not completed and a written contract with the chosen contractor in place by October 21, 2018, per the approved 53122008 RFP, the EMS Authority will recognize this Zone as being non-exclusive.

In regard to your request for ERA IV documentation, between 1979 and 1990, the EMS Authority has no records for ERA IV's RFP or Contra Costa County EMS System Plans for that time span.

If you have any questions, please contact Laura Little, Transportation Coordinator, at (916) 431-3677.

Howard Backer, MD, MPH, FACEP Director

HB:II

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