Erik Jankila

GREENWOOD TWP- Hibbing Fire Chief Erik Jankila had a consistent and perhaps unwelcome message for the Greenwood Town Board, Monday, as he presented his take on the township’s recently completed ambulance study. The ambulance services that currently cover the township will need to be part of any discussion of the future, he advised.
“None of this study will happen just if the town board asks to do it,” said Jankila, who is a Greenwood property owner himself. “You would need significant input from the providers…If the Tower and Cook ambulance services aren’t at the table…it can’t come to fruition.”
Jankila was there by invitation to provide his insights on the so-called McGrath study on ways to bring prompter advanced life support service to the township. “Everything in this study is doable,” he told the board. “But how do you get there and make it doable?”
He noted that the study failed to offer a road map to any of the four options it laid out. “That is the most important part,” he said.
Jankila has spent his career in emergency services, as a trained paramedic and firefighter, and now overseeing the Hibbing Fire Department, which employs firefighters, paramedics, and EMTs.
Jankila voiced some support for a joint powers approach to the operations of the Tower Area Ambulance Service, which is currently being explored by townships that participate in the Tower Ambulance Commission. He said Tower probably already qualifies as a regional service given the size of the region it covers. And he urged the town board to sit back down with TAAS.
“You can fix the prior problems and go back to the drawing board,” he said. “I know this is very difficult with Iron Range politics,” he told the board. “But this is not unique to Greenwood Township.”
Joint powers model
The idea of forming a joint powers district has merit, according to Jankila. “Now is the time to do it. You need to start bringing the players to the table, and not putting the blame on any one entity,” he said.
Jankila made it clear that the Greenwood town board isn’t the venue for the kind of discussion that needs to occur. “It needs to be done correctly and will take some time. The entities have to sit down together, bring together the clinics, and create a better funding system and revenue stream,” he said.
Jankila said the process of forming the Cloquet Fire District was “incredibly painful” when they did it, but the parties all understood that “the patient always comes first.” He said while that system has had a rocky start, it is moving forward in a positive way.
The political system is favoring the regional and joint powers approach, with more funding options including at the state and federal level, he said.
A joint powers agreement would be developed in an “open manner,” said Jankila.
Suihkonen agreed. “If you come to the table, we can accomplish a lot.”
Greenwood residents have expressed concerns about such a joint powers board, where Greenwood would only have one vote out of six, but where Greenwood property owners might end up paying a larger share because of its high property values.
Jankila said fire and ambulance districts are going to be adopted all over the state, because the economics no longer work for small entities.
“The little communities just can’t do it anymore,” he said. Issues facing these services include staffing, training, and finding enough volunteers and employees.
Jankila noted that the creation of a district won’t necessarily save money. “But it will put more value on the dollars that you do spend,” he said.
Without the ability to levy taxes, Jankila said ambulance services like Tower can no longer survive. “Tower is covering a ginormous area that doesn’t have a critical care hospital,” he said, which means no matter how hard they try, the current model of responses to 911 calls is not enough for the service to break even.
Jankila said Hibbing receives about 4,000 911 calls, but that the vast majority of their revenue came from its 800 transfers.
“Ambulance services without a hospital in their area are struggling for the most part,” he said, because they do not get the number of transfers, and transfers they do get require them to put in more unloaded (and uncompensated) miles,” he said.
ALS options
While some in the township have focused on establishing more regular ALS service, which is a step above the Basic Life Support, or BLS, care currently provided by the TAAS, Jankila urged the town board to take a more realistic look at the cost-benefits of that level of care.
Tower Ambulance Director Dena Suihkonen, who attended the meeting, said that ALS calls account for about 11 percent of their annual runs.
“So, for Greenwood,” Jankila said, “statistically maybe 13 calls needed ALS.”
ALS options suggested by the McGrath study included the hiring of a community paramedic either based at Bois Forte’s Vermilion Clinic, or by contracting with the Virginia Fire Department or another ALS provider, or having Greenwood hire its own paramedics.
But all of these options, Jankila noted, would require cooperation from the current holders of the ambulance service territory, Tower and Cook.
Jankila said the community paramedic model is currently being used in the metro area because the large medical providers (who are also providing EMS services) find it more cost effective to use a paramedic to provide certain types of care compared to having a patient come in for an office visit. But whether or not that model could work in a rural area is a question, he said. And in any case, the paramedic would need to be a member of the TAAS to be able to treat a patient during a 911 call.
The idea of contracting with another ALS service to have a paramedic and ambulance housed in Greenwood has major issues with how it could be funded, he said. “The primary jurisdiction [TAAS] has the authority to make the decision to transport,” he said. “There would need to be an intercept agreement.”
The only way this could be sustainable, Jankila said, would be with a rather large subsidy, of approximately $120,000-$140,000 per paramedic, plus the cost of a rig. The current reimbursement model has a “ridiculously low payment model,” he said, “especially with the high percentage of Medicare and Medicaid patients.”
Reimbursement paid for these patients is well below the cost of providing the service.
“The costs need to be seriously looked at,” he told the board.
Greenwood Interim Clerk JoAnn Bassing asked what would happen if Bois Forte got their own license to run an ambulance service on the Vermilion Reservation that would encompass Greenwood Township.
Jankila said there were several issues to consider, including how intercepts would be handled and some other liability issues. Greenwood, as well as Bois Forte, would also need to show a valid reason for pulling away from the Tower PSA.
“Bois Forte couldn’t respond to Greenwood Township without pulling out of Tower’s PSA,” said Suihkonen.
Others in the township have cited the Buhl ambulance service, which is currently being run by Essentia, as a potential model, but Jankila disagreed. He said Essentia was willing to take on the Buhl area because of its central location and relatively low number of calls, which are mainly coming from a nursing home and assisted living facilities.
“They are 15 miles away from hospitals in Hibbing and Virginia,” he said. “So, it can work.” In addition, there are financial incentives for ambulance services that are owned by the same hospital/medical networks. In Buhl’s case, he said, Essentia can subsidize the ambulance service costs and operates clinics in both locations.
And in any case, bringing in such a provider would require TAAS to give up their PSA license.
Fixing the model
Solutions to the EMS payment system are on the agenda at the Legislature this year, Jankila said, but with many competing bills, he predicts it could take a few years before lawmakers come to a workable agreement.
“We have done a terrible job of adapting to the changes in primary health care,” he said. “We are just reacting unless you are a conglomerate-owned hospital ambulance service.”
“There are eight hospital-run ambulance services that account for 80-percent of the ambulance calls in the state,” he said. “They drive the legislation.”
Twenty years ago, the funding for ambulance services matched the costs and the labor force, but they haven’t kept up with the changes in both the ambulance and medical industry.
“They want everybody to go to the mother ship in Duluth,” he said, noting the smaller rural hospitals no longer can provide care for many common medical issues.
Adding to the problem, he said, is the fact that ambulance services can’t bill for the cost of providing medical care in response to calls. Some common medications used during an ambulance call can cost hundreds of dollars.
“We carry medications that cost $500 per vial,” said Jankila, “and we are getting $400 a call.”
Jankila said there is legislation moving through this year that would allow ambulance services to create taxing districts. Other legislation would allow individual PSAs to change their boundaries, and bills to create funding for recruiting, training, and retention of EMS workers. Many of the bills are an outcome of the recent Office of Legislative Auditor’s report on the EMSRB board, the organization that the Legislature created to oversee local ambulance services.
“There are a lot of things going on,” Jankila said.
The Greenwood Ambulance Committee is holding another meeting on Monday, Feb. 6 at 6 p.m. to discuss recommendations on the McGrath study to present to the town board, as well as possibly make recommendations as to how to move forward at this time. The next regular town board meeting is set for Feb. 14.