Multnomah County passes plan to improve ambulance response times

The Multnomah County Board of Commissioners unanimously voted Thursday to approve a temporary staffing plan that aims to improve ambulance response times in the county. The decision comes after months of disagreement between the county and its sole ambulance services provider, American Medical Response.

The company hasn’t met its contractual requirement to respond to 90% of life-threatening calls within eight minutes since 2022. AMR has long blamed the delays on the county’s requirement that each ambulance be staffed with two paramedics. The new agreement will allow some ambulances to be staffed by one paramedic and one EMT through July of next year.

Multnomah County Chair Jessica Vega Pederson joins us to talk about all of that and more.

Note: This transcript was computer generated and edited by a volunteer.

Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. The Multnomah County Board of Commissioners voted unanimously yesterday to approve a temporary staffing plan aimed at improving slow ambulance response times in the county. The announcement came after a long disagreement between the county and its sole ambulance services provider, American Medical Response (AMR). The new agreement will allow some ambulances to be staffed by one paramedic and one EMT through July of next year – something the company has long argued for.

Multnomah County Chair Jessica Vega Pederson joins us now with more details. It’s good to have you back on the show.

Jessica Vega Pederson: Hi, good afternoon, Dave.

Miller: So we first talked about this issue on Think Out Loud with the county’s deputy health officer and an AMR executive back in December. That was a while ago now. So for folks who missed that conversation or other articles about this, can you just remind us what this debate has been about?

Vega Pederson: Yeah, so since about April of 2022, AMR has not been able to meet the response times in ambulance deployment that is part of the contract that they have with the county. And our ambulance response system is kind of complex, right? It’s made up of a lot of different components, including the 911 dispatch that’s run by the state of Portland, the EMS system that the county holds the contract for and then AMR is a third party responder. What was happening is that the response times that were part of the contract were not being met.

A lot of that was driven by a nationwide shortage of paramedics. So what we were experiencing here in Multnomah County from pandemic responses [and] higher levels of need in our community, that was something that we were seeing nationwide as well as the fact that we didn’t have enough workforce to meet that demand. And what we were seeing, and what the impact of that was for our community, is that ambulances weren’t getting to people at the time that was required. But also that was needed to make sure that people weren’t waiting too long for ambulances.

Miller: And just to give folks the numbers here – as part of this long standing agreement, my understanding is that 90% of the highest priority calls were supposed to have an ambulance arrive within eight minutes. Last year, at its lowest, it was only at about 50% for those highest priority calls.

So the issue really became about how these ambulances should be staffed. AMR was basically arguing two things, two things that you don’t totally disagree with. The problem, at base, was a national shortage of paramedics. They also said that it was common and safe, in many cities around the country, to have a paramedic/EMT model: one paramedic and one EMT.

In as far back as February of this year, a long list of regional stakeholders said, yes, that we actually think you should do this, that you, the county chair, should agree to switch to this model. That included Portland Fire and Rescue, Gresham Fire and Rescue, Corbett Fire, Portland Emergency Management and the mayors of Gresham and Troutdale. Why did you resist?

Vega Pederson: I think when we were considering … and really the county’s only responsibility, I will say, is the consideration of the impact on public health and safety in terms of how our emergency medical system is set up. So that was always at the center of the way that our EMS team, our health department was approaching this issue.

I think that when we look at where we are today and the agreement that we have with AMR today versus what was being proposed back then, there are significant differences. The settlement agreement that we’ve reached with them that the board has approved is a compromise of a mixed staffing model. So that preserves dual paramedic ALS ambulances. Those are the advanced life support ambulances that are really critical when there’s the highest highest need of medical care and medical response.

It also preserves something that had been piloted between the county and AMR, a way to try to address these issues before we’ve had this change, which was setting up a BLS system actually staffed by two EMTs. And that preserves the BLS system, which means that we can be deploying the right medical response to the right calls, for the lower acuity calls. And that’s something that was really important, but it does also give AMR the flexibility to have the hybrid ambulance models. And it does it in a way that we can responsibly test whether they’re able to meet the response times with this new tool and making sure that we are actually able to support the public who needs this response in the right way.

The thing that I think is very important about this mediation process and what we’ve achieved through that is that this really creates a plan that is responsible, it’s accountable. It is something that has the support of our EMS team [and] our EMS medical director, has the support of the front line responders, and it has support from AMR. And I would say that’s very different from what you were describing for the proposal six months ago, which is really a demand for me and our health department to cave to political pressure for me to override the clinical and operational expertise that we do have in our emergency response staff. And also, it was a push for change without the adequate accountability and inside boards that we do have now in this agreement.

Miller: But in terms of this model, as you’re calling it – some ambulances being EMT and paramedic, and others being two paramedics – I’m still a little bit confused how what you have now is different from what was being talked about eight months ago. In January, AMR’s Operations manager, Rob McDonald told KOIN 6, “We are confident we are at this point now where there really is only one pathway forward to sustainability in emergency medical services in Multnomah County. That’s to going to half of our total deployment being paramedic and EMT, rather than dual paramedic.”

So if it’s about half and half – that’s what he was saying was the model he said was the only obvious solution at the time – and if that’s more or less where you are now, what is the gulf?

Vega Pederson: So one thing – I think there there really had to be those conversations between our health department, our EMS folks and AMR to be able to get to a place where the actual model, both will meet the demand of the need in the public to make sure that we have the response times that we need, but that had the sideboards that were needed to make sure that we weren’t creating a system that was going too far in the other direction. And like I said before, being able to preserve that basic life support pilot with the two EMTs is really important because again, that allows there to still be enough ALS ambulances out there as well as the basic life support response. So I think that’s one of the big things.

I think the other …

Miller: And that eight months ago, I’m just curious what you got now that you’re saying you couldn’t have gotten eight months ago.

Vega Pederson: We preserved the BLS ambulances. We’ve preserved, I think, the system accountability that we really needed to make sure that we had as part of this. It holds AMR accountable for some of the things that we weren’t seeing them step up and do earlier in this process. And I can go into that, but a couple of those are really … we knew that AMR was deploying stand-by ambulances to contracts they had, where they had ambulances that were set up and were at, for instance, Portland International Raceway events where you see an ambulance on the field. And they were continuing to deploy folks to do that.

Now, this new compromise actually says that they can’t enter into any new contracts to do that. It also makes sure that we are able to get the data to the public in a way that we have been pushing for and that we think is important. And while it doesn’t limit the number of hybrid ambulances that they can put in the field – so they really can put as many as they want – it does protect, like I said, a minimum number of ALS ambulances and those BLS ambulances. And that’s especially important for our rural communities.

Our EMS director put together a really good memo in putting forward this proposal. And one of the things that was in there is that there are advantages and disadvantages to any model, including this new model that we’re going to. So making sure we are having a model that can make sure we are still protecting the needs of our rural communities was very important as well ...

Miller: I want to turn specifically to the basic life support issue, because last year when we had Randy Lauer on – he was the vice president of operations for AMR – he said explicitly that the basic life support pilot was not working. This is in which vehicles are staffed by two EMTs. He said that they had hired and trained over 50 people and that basically as soon as other EMT jobs would open up, then the folks would just leave the BLS vans and take other jobs in Clackamas County or somewhere else. Has that changed?

Vega Pederson: Yeah. So one of the things when we were talking about what’s different from the proposal a while ago is that they hadn’t been able to adequately staff those to see if that pilot would work. And I think one of the things that we were looking to see from AMR was the fact that what are the incentives that they’re doing? What are the retention bonuses? What are the training things that they’re doing to help keep and incent paramedics and EMTs to be working in Multnomah County?

I just want to remind you and the listeners today that at the time we were having these conversations about trying to figure this out with AMR, they were also going after a contract for Washington County, which was actually expanding their service and creating a new need for additional paramedics in a county right next to ours when they weren’t actually fulfilling their contractual obligations in Multnomah County. So all of this was happening at the same time that these proposals were. And again, this mediation process that we went through, this agreement that we have, I think is really important to holding AMR accountable for what they’re contracted to do. But also recognizing that we want to be flexible with them in terms of deploying a hybrid model, while still keeping the public safety across the entire county at the center.

Miller: What does accountability mean when you’re dealing with a company that you’ve already levied fines against for a year, fines that they haven’t paid? And we can talk about how those fines, millions of dollars that have been accrued now, at this point, could be addressed in this agreement. But what does accountability mean?

Vega Pederson: The fines and the fact that we had levied fines against them is actually what got us to this point today to have this agreement with them. And I think initially, when this first started before I became chair, there was this feeling of like, let’s not levy the fines, let’s really find out what we can do in terms of recruiting more people, having more training and retention for folks. That didn’t work.

When I came on this chair, I decided to levy fines against them because they weren’t meeting the contract, in the hopes that that would actually make some concrete differences in what was happening. What it did is it really brought them to the table in a very serious way. Instead of just having external pressure of demanding a change in the system, they were sitting down with our EMS team and the county team to really say, like this is an agreement we’re going to get to that takes into consideration not just this demand to change the model, but also these other things that were important to the county in terms of them being accountable to the public.

Miller: So going back to the single number that I think we’ve been paying the most attention to publicly – the response times for the most urgent calls. Again, the requirement contractually is that 90% have to be responded to within eight minutes. The lowest point was around 50%, I think in October of last year. In June, according to data that Willamette Week got in a recent records request, it was still only at 70%.

When do you expect to see a measurable drop in response times, an increase in the rate that actually meets the requirement?

Vega Pederson: Yeah, I mean, I have very high expectations for AMR over the next 12 months. I believe they can be successful in this new model and so does our team, which is why they endorsed this plan. What we have in this contract is really a three month ramp up, right? Because we know it’s gonna take some time to switch over … although I will say I heard from AMR yesterday that they were able to deploy the first hybrid ambulance as of 2 p.m., or 2:30 p.m., yesterday. So, this model is already being put into effect. But in the agreement, there’s a three month ramp up time.

Then after that three months, we will start holding AMR accountable for meeting those response times. And what this looks like in terms of fees going forward, we’re agreeing to hold the fines and advances through this agreement, but we are leveraging the fines that they have accrued to support their compliance with the response time. After 30 days for the rest of this kind of agreement period for the next year, as they reach the response times each month, one-ninth of those fines would be credited. So we’re really pushing for them to meet those response times and we’re holding those fines, as the way of holding them accountable for that.

Miller: Finally, just a little bit of a change of subject here – big change of subject. And I should note that we’re going to have a much more in-depth conversation about the county’s Planned Deflection Center in a few weeks, the post-Measure 110 infrastructure. We plan to do that with you, the Multnomah County DA, the sheriff and the Portland police chief.

But just today, for now, I’m curious – given that there’s been a lot of coverage in the last week or so about safety questions and about timing, are you still holding to a September 1 opening for this center?

Vega Pederson: I have been pushing for a September 1 timeline because we know that is when the part of House Bill 4002 that recriminalizes a personal amount of drugs goes into effect. And I want to make sure that we have both plan in the system in place. So that jail is not the only option for people who have addiction, right? And so setting up a deflection system, which includes in Multnomah County a deflection center, is a really important piece.

So having a deadline, setting some expectations of when we’re going to do that, I think is an incredibly important thing for any major project. But I’m also really insistent on, when we open up, this needs to be a safe, beneficial resource for our community [and] that this center is going to be the resource that law enforcement has been asking for. It’s going to be that place where people get the connections to the health care system. So the safety for the people both inside that building who are coming in, for the people who are outside that building, that’s a critical piece to all of this.

I would never hold to a date if those things were in place. Everyone at the county, so many of our partners are working just as quickly as possible to be ready for that opening, but we want to make sure that it’s going to happen. I’ll say overall, Dave, that the benefits to our community and having this resource, the benefits of having this pathway of a place where people can go to get connections to more stability, more safety, housing, treatment, resources that they need, that’s really critical and that’s a bonus for all of us.

Miller: As I mentioned, we will talk much more in depth about this in the coming weeks. Jessica Vega Pederson, thanks very much.

Vega Pederson: Thank you, Dave.

Miller: Jessica Vega Pederson is the chair of the Multnomah County Board of Commissioners.

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