TOWER— The Tower Area Ambulance Service faces a number of challenges to its survival and will likely have to make significant changes in order to succeed. Yet it retains a dedicated staff that takes pride in the service and wants to see it thrive. Those were among the findings of the rural ambulance assessment report issued Monday to the Tower city council by the state Emergency Medical Services Review Board.
The EMSRB review panel had visited Tower back in early May, and interviewed dozens of stakeholders in the community, including ambulance personnel, city officials, and community and business leaders. The state agency conducts several such assessments annually and came to Tower at the request of city officials.
EMS specialist Charles Soucheray presented a high-level summary of the board’s findings before handing out copies of the 83-page report to members of the council, along with township representatives and media.
Soucheray’s presentation focused mostly on personnel challenges, such as strategies for recruiting and retaining ambulance personnel, attracting and retaining experienced and trained leadership, and creating opportunities for members to enhance their skills. He said discussions with ambulance personnel indicated that current ambulance supervisor Dena Suihkonen is generally viewed positively, although some maintain concerns about her limited leadership experience. Soucheray noted that training is key to building the TAAS’s leadership capacity.
The report itself, a copy of which was obtained by the Timberjay, focuses primarily on TAAS’s financial struggles, and lays out three operational scenarios moving forward. While none of them showed the ambulance service operating at a profit, the EMSRB recommended a scenario that brought the service close to break-even.
Maintaining the service’s current operational model, on the other hand, would likely lead to deficits of close to $100,000 annually, even assuming the service begins taking large numbers of inter-hospital transfers again. That’s true, in large part, because of the extraordinarily high wages that the service set for its paid on-call personnel when it shifted to that model back in 2018. The consultant retained by the EMSRB for the financial analysis stated that the firm was not aware of any ambulance service in Minnesota or Wisconsin that paid on-call staff as high a wage rate as in Tower. Currently, on-call EMTs are paid $11.50 an hour, while EMRs are paid $10.50.
Most other services around the Upper Midwest pay in the range of $4-$6 an hour for staff who are on-call, according to the report. “The current paid on-call structure is costly and inherently brings some additional risks related to FLSA and IRA rules on on-call,” wrote the consultants, referring to the federal Fair Labor Standards Act and the risk of overtime liability under federal law. “Essentially, TAAS is paying on-call staff what could be considered a livable wage, which is not how on-call staffing is intended to function,” noted the consultant.
The on-call system was put in place in 2018 by former ambulance supervisor Steve Altenburg, with approval of a prior city council. The concerns now raised by the EMSRB were raised at the time by this newspaper but were dismissed by Altenburg and the city council.
Since Altenburg’s dismissal, city officials have discussed the need to reduce the on-call pay rate but have faced pushback from some on-call staff that have grown used to the exceptionally high pay. The EMSRB recommendation may provide greater justification for the city to make the needed adjustments.
City records highlight just how much some ambulance personnel are currently earning from the paid on-call system that Altenburg established. Since the city council ended the prohibition on incurring over 40 hours per week in on-call time earlier this year, the highest paid EMT in the city is now on track to earn approximately $95,000 in annual pay, for a schedule that averages about 15 hours per week of actual work time. That’s far higher than any other city employee, although the position does not come with health benefits.
Despite the exceptionally high cost of the city’s on-call system, Soucheray noted that pay is typically not the primary motivator for ambulance staff, who are more often encouraged by the camaraderie and sense of pride that most services develop. The financial consultant agreed ,and questioned whether TAAS’s on-call pay structure actually benefitted the service’s recruitment and retention of ambulance personnel.
The report highlights the fact that the ambulance service has not engaged in realistic budgeting or financial accounting for years and that it is only beginning to establish true accounting of its expenses. One of the major expenses that the service has not calculated in the past is depreciation, which is one of the largest line items in the budget of most other ambulance services. The consultant pegged the ambulance service’s annual depreciation at $72,567, a figure that has a substantial impact on projected surpluses going forward. This expense had never been accounted for in city financials.
Scenarios outlined
The financial report lays out three distinct scenarios, including continuing with the status quo, converting to an all-paid career ambulance service with full-time personnel, or its recommended option, which reduces on-call pay to $5 an hour for all on-call personnel, regardless of their certification level. Activation or duty pay for all personnel would be set at $25 for EMTs and $20 for EMRs.
All of the scenarios include an increase in the number of inter-hospital transfers, from the current relatively low number to approximately 100 per year. The consultant concluded that the TAAS does generate about $448 in profit, on average, from transfers, and recommended that the service take advantage of that revenue stream, but only after it has stabilized its 911 emergency capabilities. All of the scenarios also assume that the TAAS will begin to comply with state law that requires that all ambulance services maintain fully-staffed on-call schedules 24 hours a day, seven days a week. Soucheray noted that the TAAS has not been in compliance with that requirement for years. The report also recommends that the service reduce its ambulance fleet from three vehicles to two.
Even assuming a substantial increase in transfers, the EMSRB’s financial consultant concluded that the status quo, labeled Scenario 1, would lead to a $90,629 deficit in 2022 and slowly increasing deficits in subsequent years. The EMSRB concluded that maintaining the status quo required the least change, but that it would leave the TAAS unprepared for the future and keep it saddled to a very expensive labor model that appears to provide few benefits.
Converting the service to a full-time, career ambulance service, labeled Scenario 3 in the report, would likely provide the most reliable staffing model, noted the report. But it would also be extremely expensive, leaving the TAAS with a projected $379,979 deficit next year and growing deficits after that. Those shortfalls would need to be made up primarily from taxpayer dollars, notes the report.
The EMSRB’s recommended model, labeled Scenario 2, would provide the least financial drain, with a projected deficit of $2,325 next year, slowly rising to $11,288 by 2025. The recommended scenario would “bring TAAS in-line with similar ambulance services as it relates to on-call and duty pay,” notes the report. It would also help ensure strong and reliable leadership by creating a full-time ambulance manager position with a full city benefits package and greater authority over the service. The current ambulance supervisor is considered part-time and reports to the clerk-treasurer rather than the city council, but would likely report directly to the council under the recommended scenario.
Other concerns
The EMSRB also highlighted a number of other concerns that appeared to be impacting the service, undermining its financial status as well as hampering staff morale. The report noted that TAAS’s previous ambulance supervisor chose to sign a contract with a large commercial insurance company for the years 2017-2020, that willingly discounted TAAS’s rates for inter-hospital transfers to at or near Medicare reimbursement rates. “This agreement cost the city tens of thousands of dollars in lost revenue for those years combined, which was ultimately made up by tax- paying citizens,” noted the report. TAAS has since discontinued the agreement.
The report also expressed concern that ill feelings generated in the wake of the dismissal of the prior ambulance director had created divisions, or “camps” within the ambulance service which were undermining the service’s cohesiveness and morale. “A great amount of ambiguity exists over roles and responsibilities related to the termination of the previous ambulance manager, his role in the negative publicity of the service, and those who may have been hired under his direction,” noted the report.
The former director, who now regularly reports negatively on the city and ambulance in the Tower News, prompted the EMSRB to note that one of the newspapers in town is currently “creating quite a bit of conflict without stating all the facts.”
Soucheray, in his comments to the city council on Monday, noted that “myths and rumors” in the community were making it difficult to move forward. “It’s time to leave the past in the past and move on to build something really good,” he said.
While chiding one newspaper, the report also cited the value of the reporting by the other newspaper in town. “Years’ worth of local newspaper articles relating to TAAS, while certainly uncomplimentary of previous city of Tower and TAAS leadership and practices, have shed light on the need for change,” said the EMSRB, clearly referring to reporting by the Timberjay.
The EMSRB notes that the service still has some fence-mending to accomplish with neighboring communities, which contribute financially to the TAAS. Soucheray said talk of missing money isn’t an issue that the EMSRB addressed and said that the city could hire a forensic accountant if it wants to settle that issue.
Improving relations with partner communities is valuable, said Soucheray, since the TAAS is likely to need an increase in the per-capita contributions to sustain itself financially.
Overall, the report strikes a generally optimistic tone about the future of the service and the desire for improvement. “A change to the ambulance leadership in 2020 brought new ideas, fresh energy, and a willingness to improve the current state of TAAS,” wrote the consultant. “With this leadership change, there is the potential for an effective ambulance service and a rebuilding of trust amongst all staff and city leadership. This trust between leadership and staff is a fundamental requirement for the retention of staff.”
Soucheray said the TAAS should also do more to increase its public presence and establish ways to build its brand and demonstrate its professionalism in the community. He said such steps will increase trust, build community support for the service, and aid recruitment and retention of new members. “Building positive relationships with stakeholders is imperative to creating success,” he said.
Soucheray recommended that the city establish a working group to examine the report’s findings in detail and to help implement changes to the service’s operations. In doing so, he said the city and TAAS need to move forward with a unified front. He urged the members of the council to read the report thoroughly and he offered to answer any questions they might have after they’ve had time to do so. He said the EMSRB staff hopes to continue to work with TAAS as it seeks to make the changes necessary for success. “If you’re willing, we’d like to return in a year to check in on your progress,” he said.
Reaction
Ambulance supervisor Dena Suihkonen said she was still working her way through the voluminous report, but said she expects it will prove to be “an invaluable tool” in helping to reshape the service. “I believe that we learn from both compliments and constructive criticisms and believe this report will bring with it a new beginning,” she said.
Suihkonen also noted that some of the concerns raised in the report have already improved since the EMSRB evaluators came to Tower in May. “I believe that even in the short span of time since May, I am seeing a lessening of the “camps” noted in the report,” Suihkonen said. “We have acquired new members and with that are seeing our long-standing members enjoying helping our new members become involved. New members are the lifeblood of rural services and we look forward to having more members join us.”
Suihkonen said the TAAS has also been making a greater effort at outreach, noting that the service had a presence at the Old Settlers picnic as well as at the Breitung Fourth of July picnic.
“The ability to show others our amazing equipment without being involved in a medical emergency is fun for both our crews as well as the community and we are planning future opportunities to engage the community with our members,” stated Suihkonen.
The Timberjay also reached out to Steve Altenburg for comment on the report. He did not respond.