An Open Letter to Mayor Fulop and the City Council of Jersey City Regarding Basic Life Support (“BLS”) EMS Contract

This letter was emailed to the Mayor and all nine City Council members on December 26, 2013 at 11:04am.  

Date:        December 26, 2013
From:       Brigid D’Souza, Yoo Lee, Matt Schoenfeld
Subject:  Concerns Regarding Basic Life Support (“BLS”) Emergency Medical Services (“EMS”) Contract
To:            Mayor and City Council of Jersey City

Dear Mayor Fulop and City Council Members,

We have concerns about the process undertaken by Jersey City (the “City”) to change the City’s provider of Basic Life Support (“BLS”) Emergency Medical Services (“EMS”).  We ask that you (i) provide greater transparency into the decision making process by answering the questions posed below and (ii) delay the council’s vote on the BLS contract until the public has been afforded time to understand the options the City faces.

We are a group of concerned citizens[1] and have endeavored to research, compile, and synthesize the facts as we understand them.  EMS is a critical component of our local healthcare system and our existing provider, Jersey City Medical Center (“JCMC”) EMS, is a nationally recognized model for EMS.  As such, we feel the public should have reasonable assurances that any change in that service provider is justified and reasonable. Further, we feel the public should be afforded the opportunity to question and challenge the City’s decision-making processes if those processes appear to be inconsistent, non-transparent, or poorly communicated by the City to the public.

This letter contains the following:

1. Facts
   a. The Bid Process for BLS Contract Starting January 1, 2014
   b. History of Jersey City’s Current EMS Provider, JCMC
2. Our Concerns
   a. Cost
   b. Quality
   c. Transparency
   d. The Bid Process

FACTS:

The Bid Process for BLS Contract Starting January 1, 2014.  On September 27, 2013, Jersey City (“the City”) issued a request for proposal (“RFP”) for a three year BLS contract to commence on January 1, 2014, with an option to extend to five years.  Bids were due on November 13, 2013 and the Mayor’s office announced the selection of CarePoint Inc./McCabe Ambulance (“CarePoint/McCabe”) on December 13, 2013.  A City Council vote was scheduled for Wednesday, December 18, 2013, but was removed from the City Council agenda that day for legal reasons.  The City Council instead voted to enter into a month-to-month contract with JCMC. There has been no announcement rescheduling the vote on the BLS contract and no further information provided to the public explaining the legal reasons for the deferral of the December 18 vote. The next City Council meeting is scheduled for January 2, 2014; this is the next potential date that the City Council could vote on the BLS EMS contract.

History of Jersey City’s Current EMS Provider, JCMC.[2]  From 1988 (the first year JCMC was an independent non-profit) until 2005, JCMC provided BLS services to the City at no cost.  In 2005, JCMC was near bankruptcy.  The fleet of vehicles was “on its last legs,” equipment was worn down, and old construction trailers were used as makeshift EMS offices.  The JCMC EMS system “lacked the efficiencies of a high-performance system.”  In 2006, JCMC began charging the City approximately $4M per year for its services and took the following measures:

• JCMC hired Washko & Associates, an EMS consulting firm, to help turn the organization around.
• JCMC brought billing in-house and implemented a modern, electronic patient care report platform, both of which improved revenues.
• JCMC partnered with Hudson County Community College to offer an associate’s degree program in paramedic science, the only degree program in NJ and the first CoAEMSP-accredited program in NJ.
• JCMC updated its EMS communications center
• JCMC invested in new infrastructure, including a new building, a new training and simulation center, a new ambulance speed loading system, and new maintenance facilities and staff
• JCMC invested in new vehicles, including ambulances outfitted with cutting-edge safety devices
• JCMC invested in new medical equipment and the following technologies:
  • VisiCAD
  • MARVLIS (Mobile Area Routing and Vehicle Location Information System), profiled by CBS News in August 2013
  • FirstWatch
  • International Academy of Emergency Dispatch’s (IAED) advanced medical priority dispatch system
  • ZOLL RescueNet Crew Scheduler
  • ZOLL RescueNet TabletPCR
  • Physio-Control Inc’s LIFENET
  • General Devices CAREpoint console
  • Eventide
  • SharePoint server

To validate its efforts, JCMC then earned the “royal flush” of accreditations[3]:

• Commission on Accreditation of Ambulance Services (CAAS) – the “gold standard” of modern EMS programs and EMS system design.
• International Academy of Emergency Dispatch’s (IAED) Accredited Center of Excellence (ACE) – best use of medical priority dispatch system (MPDS) emergency medical dispatch program.
• Commission on Accreditation of Allied Health Education Programs (CAAHEP) Committee on Accreditation of Educational Programs for the Emergency Medical Services Profession (CoAEMSP) – upcoming 2013 requirement of training programs who wish to provide students with National Registry of EMT certifications.
• National Academy of Ambulance Coding (NAAC) Certified Ambulance Coder (CAC) – standards of excellence in compliance, ethics and integrity in all facets of ambulance billing and coding. 
• National Institute for Automotive Service Excellence (ASE) – excellence and certification of mechanics for automotive repair and maintenance.

OUR CONCERNS:

1. COST

1.1.  First Responder Services.  First responder services are currently provided by the Jersey City Fire Department (“JCFD”). The City RFP computed “First responder service” at  $2,663,245.91[4], consisting of personnel and vehicle costs.  The RFP also stated “the Vendor shall provide First Responder Service, or may reimburse the City for the City’s provision of First Responder Services.”[5]  JCMC’s zero ($0.00) dollar bid was inclusive of “First responder service.”[6].  CarePoint/McCabe offered to pay the City $2,663,245.91 to provide first responder service[7].

The City has cited “$2.6 million” as the financial justification to select CarePoint/McCabe over JCMC[8].

1)    Is $2.6 million in the form of a payment from CarePoint/McCabe more beneficial to the City than $2.6 million in the form of services from JCMC?  If yes, why?

2)    If JCMC were to provide first responder services, then would the City no longer have to pay $2.6 million to the JCFD for first responder services?

3)    If JCMC were to provide first responder services to the City, then would there be infrastructural investments within JCFD that would go under-utilized?  If yes, what is the financial impact to the City?

4)    If CarePoint/McCabe were to provide first responder services to the City, then would there be infrastructural investments within JCMC that would go underutilized?  If yes, what is the financial impact to the City?

5)    If CarePoint/McCabe were to pay the City $2.6 million per year for first responder services to the City, what overhead / administration expenses (if any) would the City assume in managing this payment process?

2. QUALITY

2.1.  Accreditation.  JEMS described the EMS accreditation process as “a tool to transform…organizations from mediocre to great.”

1)    Does CarePoint/McCabe have accreditations in addition to those listed on its website?

2)    How, if at all, did accreditation factor into the committee’s evaluation of quality?

2.2.  Technology.  JCMC uses the MARVLIS technology that was profiled by High Performance EMS blog and CBS News as being “an advanced computer technology system.”  MARVLIS enables “pre-positioning,” whereby ambulances are deployed to specific locations (e.g. a specific intersection) in the assumption that “trends in historical data can predict future incidents.”  MARVLIS and the pre-positioning approach have helped the JCMC reduce response times to less than 6 minutes.

1)    Does CarePoint/McCabe use MARVLIS?

2)    Does CarePoint/McCabe use FirstWatch?

3)    Does CarePoint/McCabe employ the “pre-positioning” approach to deployment?

2.3.  Vehicles, Other Equipment, and Supplies. To operate in Jersey City, CarePoint/McCabe has stated its intention to “build garages in several areas of Jersey City to increase response times.”

1)    Was the City aware of these infrastructural needs when it evaluated the bids?  How does the City reconcile this shortfall in current capacity and infrastructure with “quality” and “cost” as per the detailed evaluation sheets used to score each bid?

2)    Does the City have land that CarePoint/McCabe can use for the new ambulance garages?

3)    How did the need for additional land factor into the City’s bid evaluation?

 2.4.  Risk. Section 2.3 of the City’s RFP states that a representative from Risk Management would be on the committee to evaluate the bids.

1)    How was risk evaluated and quantified with respect to switching from JCMC to CarePoint/McCabe?

3. TRANSPARENCY

3.1.  Communications from City Hall.  There is no press release on the City’s website explaining the decision to recommend CarePoint/McCabe as the next BLS EMS provider.  The committee’s evaluation worksheets were provided with the City Council agenda, showing three evaluators scored CarePoint/McCabe higher and two evaluators scored JCMC higher.  Further, JCMC scored higher in total points (1,201) than CarePoint/McCabe (1,191)[9].  Yet Mayor Fulop stated that the differences between the two bids were “night and day.”

1)    Why is there no press release on this contract explaining in detail the reasons for the change in vendors?

2)    Can the City substantiate or given insight to the mayor’s claims that the two bids are “night and day”?

3.2.  “Subsidy” vs. “Investment”. The City has characterized the payment to JCMC starting in 2006 as a “subsidy.”

“Subsidy” connotes a payment to enable the continued sale or operation of a product or service at a below-market price[10]. The money paid to JCMC starting in 2005, however, was invested in new buildings, vehicles, equipment, technologies, and management consulting fees to aid what JEMS characterized as “epic efforts” that “set a new standard for overcoming adversity, EMS system redesign, clinical excellence, and employee acceptance.”

1)    Why is the City using the word “subsidy” instead of “investment” or “fee”?

2)    What alternatives did the City have in 2006 other than paying JCMC for its BLS EMS contract?

3)    Has the City considered what will happen to the JCMC BLS-related resources that were procured starting in 2006?  For example, if the ambulance contract is provided to CarePoint/McCabe, will technologies already purchased with Jersey City tax dollars, such as MARVLIS and FirstWatch, lose operational utility?  If so, what will the financial impact be to Jersey City?

4. THE BID PROCESS

4.1.  Timeline. The public was notified of the City’s choice of BLS EMS on December 13, 2013.  This was 3 business days prior to the City Council’s scheduled vote on the BLS EMS contract and 11 business days prior to the December 31 expiration of the current contract.

1)    Was the City Council notified at the same time as the public that CarePoint/McCabe was the City’s preferred provider?  If yes, then was three business days sufficient time for the Council to review and understand this contract, the City’s reasoning for changing providers, and the transition plan that would have to be undertaken to ensure continuity of EMS service?

2)    Was the City’s expectation that CarePoint/McCabe would be capable of starting on January 1, 2014?

 4.2.  The Selection Committee.  As we understand it, no one on the BLS EMS selection committee was a medically trained professional (MD, RN, LVN, EMR, EMT, AEMT, etc.).

1)    Is it typical to not include a professional from the field being evaluated when evaluating contracts of this sort?

2)    Were any committee evaluators independent of Jersey City, i.e. not employed by the City?

4.3.  Cost. JCMC confirmed in Section 5.21 of its bid, and again in written correspondence with the City on December 12, 2013, that it would provide first responder services as part of its zero dollar cost bid.

1)    Why did JCMC receive a zero (0) score for “First Responder Services (or reimbursement)” and/or “first responder training” from Stacey Flanagan, W. Kierce, and Peter Soriero in the evaluation worksheets?

2)    Would the $2,663,245.91 currently paid by the City to the Jersey City Fire Department (“JCFD”) for First Responder Services no longer be a cost to the City if JCMC were awarded the contract?

3)    If the bids are identical from a cost perspective (as they appear to be), why is there a discrepancy in scores among the five evaluators?

4)    Bid evaluator Bob Kakoleski assigned a score of 50 points to JCMC for “Cost Proposal.”  But the other four evaluators assigned scores of 25 points to JCMC for this same category. Are there qualitative factors in the “Cost Proposal” section that would result in each evaluator assigning different points to “Cost Proposal”?

 4.4.  Technology. We did not see any category in the Committee’s evaluation worksheets dedicated to technology.

1)    How or where was technology scored or factored into the bid evaluation?

4.5.  Dispatch. The use of dispatch-related technologies such as MARVLIS and FirstWatch are used by JCMC but not CarePoint/McCabe.  MARVLIS enables JCMC to dispatch ambulances to likely call areas based on historical call volume (this is the “deployment” model). Bob Kakoleski, W. Kierce, Peter Soriero, and Bhavin Doshi all scored both bids equally in the “Dispatch” category.

1)    Does CarePoint/McCabe use similar dispatch technologies?

2)    If not, what was the rationale for scoring “Dispatch” equally given the difference in dispatch-related technologies used by each provider?

3)    JCMC uses the “deployment” model of dispatching ambulances in conjunction with software such as MARVLIS and FirstWatch; what deployment model does CarePoint/McCabe use?

4.6.  Vehicles, Other Equipment, and Supplies. The JCMC bid states its fleet size as “41 ambulances and 12 support vehicles.”  The CarePoint/McCabe does not include an inventory of vehicles.

1)    Did the City confirm the CarePoint/McCabe fleet size as part of this bid process and if so, what is the fleet size?

2)    How many vehicles would CarePoint/McCabe need to procure in order to take over the Jersey City BLS EMS contract?  How long would it take CarePoint/McCabe to procure the vehicles?

4.7.  Prior Experience/References.  CarePoint/McCabe entered into a 5-year contract with Secaucus in 2011.  By 2012, Secaucus was no longer contracting with McCabe Ambulance.

1)    Did the selection committee or the City inquire about this with any official(s) from Secaucus?

2)    Bob Kakoleski and Bhavin Doshi scored CarePoint/McCabe 40 points for this category yet the other three evaluators scored only 20 points; what is the reason for this difference in scoring?

*  *  *  *  *

We request that the City provide clarification on these questions prior to the January 2, 2014 City Council meeting.  We recognize there may be reasonable explanations to these questions, but in the absence of information from the City or an in-depth explanation in the local press, we do not understand the actions taken, or the comments made, by the Mayor and the Council on this matter.  We believe the public should be afforded time and opportunity, prior to the City Council vote on the BLS contract, to understand fully the facts and circumstances that led to the City’s decision to replace JCMC EMS with CarePoint/McCabe EMS.

Respectfully,

Brigid D’Souza
Yoo Lee
Matt Schoenfeld