March 27, 2003

Michael L. Subin
County Council Office Building
100 Maryland Avenue
Rockville, Maryland 20850

Dear Council President Subin:

I am writing on behalf of the Bethesda-Chevy Chase Rescue Squad, Inc. (BCCRS) to express our strenuous opposition to the "ambulance user fee" as proposed in the County Executive's FY2004 budget. Our opposition to the proposed ambulance user fee can be summarized as follows:

• The ambulance user fee would jeopardize the health and safety of Montgomery County citizens by discouraging them from calling for an ambulance or paramedic at the earliest possible sign of a heart attack or other life-threatening medical emergency.
• The ambulance user fee would fall most heavily on the elderly and others least able to afford it.
• The revenue estimates supporting the ambulance user fee appear to be extremely inflated. Indeed, when the administrative costs of collecting the fee are added to the cost associated with the loss of donations to the local fire and rescue departments, the ambulance user fee is likely to generate little or no revenue for the County's fire and rescue system.

As explained in more detail below, we urge the County Council to quickly and decisively reject the imposition of an ambulance user fee.

User Fee Will Jeopardize Public Health and Safety

Imposing a user fee on ambulance and paramedic service will deter people from calling 9-1-1 at the earliest sign of a heart attack or other life-threatening medical emergency. Study after study indicates that early activation of the EMS system is essential in the successful pre-hospital treatment of heart attacks, strokes, respiratory distress, traumatic injuries, and other serious medical emergencies. The County has invested tremendous resources in educating the public about the need to call 9-1-1 quickly for medical emergencies. Imposing an ambulance user fee will undercut these efforts and deter

people from calling 9-1-1 in times of serious need. This will undoubtedly jeopardize citizen health and safety.

Disproportionate Impact on the Poor and Elderly

The burden of the ambulance user fee will fall most heavily on the elderly and those least able to afford it. A high percentage of the citizens using the EMS system are elderly and low-income individuals, many of whom live on fixed incomes. The proposed ambulance user fee may force such individuals to choose between calling for an ambulance for a medical emergency or having enough money to pay for food, housing, and other essentials.

Even if a scheme is devised to focus on reimbursement from individuals with health insurance, many health plans impose a "co-payment" charge on individuals. Medicare, for example, charges a 20% co-payment. For advanced life support (paramedic) services, this could result in a co-payment of almost $100 for users of the EMS system (based on Medicare's current ambulance fee schedule). Statements by Fire Administrator Gordon Aoyagi that uninsured patients will not be "forced to pay"[1] offer little comfort to elderly and other patients who will receive collection notices and calls from insurance companies and their collection agents. Ultimately, the insured will shoulder the cost of the uninsured.

Revenues Are Exaggerated, Costs Are Hidden

The County Executive's proposal estimates the ambulance user fee will generate $4,000,000 in FY2004, while costing $1.6 million to administer. The Fire Administrator has stated that the fees will be set at $350 for ambulance service and $650 for paramedic service, Medicare reimbursement (which tends to be equal to or greater than Federal or private insurance reimbursement) for these services is approximately 60% of the Fire Administrator's proposed charge. While neither the County Executive nor the Fire Administrator has provided figures to support its revenue estimates, it appears clear these projections supporting the ambulance user fee are extremely exaggerated if users are not going to be expected to pay the difference between the County charge and insurance payments.

We are also concerned about the unintended consequences of the ambulance user fee. The Local Fire and Rescue Departments, through which much of the EMS service is delivered in the County, derive a significant portion of their operating funds through voluntary donations from citizens and businesses. Many donors will stop giving voluntarily if they will be charged for calling for an ambulance or paramedic unit. The ambulance user fee proposal neither addresses the loss of these revenues nor the impact on the LFRDs.

In addition, the imposition of an ambulance user fee may subject the County's EMS system to the new Federal HIPAA privacy regulation (which applies to certain health care providers that charge for their services). Under the HIPAA privacy rule, providers are required to establish elaborate safeguards to protect the confidentiality of personal health information. The costs of complying with HIPAA, alone, could exceed the projected revenue from the ambulance user fee.

Hasty Process Leaves Many Unanswered Questions

Finally, we are extremely troubled by the hasty process under which the ambulance user fee proposal was developed. None of the stakeholders in the County's Fire and Rescue System - including the LFRDs, community groups, or individual citizens - were consulted about the proposal. The proposal is accompanied by no supporting analysis or projections. As a result, countless important questions have not been addressed, including:

• How will the ambulance user fee be imposed and collected?
• What impact will it have on elderly and low-income individuals?
• How will these vulnerable individuals be protected against collection efforts from insurance companies seeking to recoup all or a portion of the fees?
• What impact will the new user fee have on voluntary donations to the LFRDs? How, if at all, will the County make-up for these lost revenues?
• Is the ambulance user fee a temporary proposal - or will this be a permanent new fee imposed on users of the EMS system?

These are, of course, only a handful of the unanswered questions surrounding the proposed ambulance user fee. We urge the County Council to consider these issues carefully, and to seek the input of the various stakeholders in the County's EMS system, before any consideration of a new ambulance user fee that could jeopardize the health and safety of County residents, particularly the elderly and other low-income individuals.

* * * * *

In conclusion, we urge the County Council to reject the ill-considered ambulance user fee proposal in the County Executive's FY04 budget proposal. We would be happy to meet with you or your staff to discuss our concerns.

[1] The Washington Post, March 18, 2003, B1.